Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested Alveoloplasty of two quadrants.
You asked the Plan to pre-approve the alveoloplasty. You say that these services are medically reasonable and necessary due to the enrollee's bone loss and her need for endosteal implants. The Plan denied your request. The Plan says this is not a covered service.
Medicare generally does not cover dental services. The Plan follows the same rule. In this case, an alveoloplasty is considered a dental procedure as it is being requested to facilitate replacement of the teeth with dental implants. Although the need for implants may be due to a medical condition, services related to teeth replacement are dental by definition and cannot be covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the requested Alveoloplasty of two quadrants.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan denied your request. The Plan says this request is a 55-mile overage.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the individual trips do not exceed 50 miles one-way. We looked at your request, the records in the case file, and the rules. The requested trip is longer than 50 miles one-way. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional LogistiCare mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (CPT Code 99223) provided to the enrollee on July 22, 2019. You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Per CMS guidelines, both initial hospital care and subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.Therefore, we decided that the Plan does not have to pay for initial hospital care (CPT Code 99223) provided to the enrollee on July 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided by OUT OF NETWORK (OON) PROVIDER on April 1, 2019.You asked the Plan to waive the copayment forambulance services. You say that you did not request the ambulance services and it was against your will.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forambulance services provided by OUT OF NETWORK (OON) PROVIDER on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 25, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that when you called to make the appointment you were assured that this provider would be covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 29, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on April 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an eye exam provided on September 30, 2019.
You asked the Plan to waive the coinsurance for an eye exam. You say that you were told that you would not owe anything. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network vision care. You had an eye exam with an out-of-network provider on September 30, 2019. The allowed amount is $151.37 and 50% of that is $75.68. You have been asked to pay the total coinsurance amount of $75.68 for an eye exam. An eye exam falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an eye exam provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that if a prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50% symptom improvement, insignificant or indiscernible relief), a second epidural injection utilizing the same method, technique or medication to the same level will be considered not medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our reviewer says that the service is not medically necessary. Our physician reviewer found in this case, the prior epidural injection procedure provided limited or no relief (i.e., NPRS less than 3, less than 50% symptom improvement, insignificant or indiscernible relief). The review has determined that you do not meet the criteria. The requested second epidural steroid injection is not medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tab 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone tab 5mg for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued daily respiratory therapy services in a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF service. You say that the enrollee needs to have respiratory therapists tend to her every few hours. The Plan denied your request. The Plan says the denial of authorization for continued skilled care in a SNF is correct, because the enrollee has exhausted the 100-day covered SNF benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from October 31, 2019 to February 8, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued daily respiratory therapy services in a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services: medical
examination and evaluation, with initiation or continuation of diagnostic and treatment program;
comprehensive, established patient, 1 or more visits (CPT Code 92014) provided on December 6, 2019.
You asked the Plan to waive the copayment for the services. You say that this was a routine eye exam. The
Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
The provider billed the services as ophthalmological services: medical examination and evaluation, with
initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more
visits (CPT Code 92014); therefore, the services were not routine. You are asked to pay a $30 copayment for
the specialist office services. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological services:
medical examination and evaluation, with initiation or continuation of diagnostic and treatment program;
comprehensive, established patient, 1 or more visits (CPT Code 92014) provided on December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that these services should be considered urgent/emergent due to the diminishing viability of a specimen, and you had no direct involvement with the enrollee so could not request prior authorization.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Pan and prior authorization wasnot obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on February 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on June 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99213) provided on November 6, 2019 through November 13, 2019.
You asked the Plan to pay for the office visits. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for these services is included in the payment for the surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for preoperative and postoperative visits. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visits have not been met. Specifically, payment for this service is included in the payment for the surgical procedure. Therefore, we decided that the Plan does not have to pay for the office visits (99213) provided on November 6, 2019 through November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 28, 2019. You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses were not medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthoses (L1851) and suspension sleeves (L2397). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer found the enrollee's chief complaints were right knee pain and left knee pain, documented in 2 separate notes on the same date of service. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1851) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided by on August 28, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that you need the additional PT to avoid
surgery and to fix the pain in your neck that resulted from an uncomfortable fall on your right side. The Plan
denied your request. The Plan says continuation of PT services is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your
condition. Our physician reviewer found based on the medical records provided, the documentation does not
support the medical necessity of additional PT visits. The therapy would not be generally accepted as specific
and effective therapy for your condition as you have had extensive therapy for this condition. The records do
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide
treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision
of a therapist. You should be able to transition to an independent home exercise program at this point for range
of motion, strengthening and pain management.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary.
The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our physician reviewer found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the
purpose of diagnosis. This patient was treated under an individualized treatment found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.