Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four (TOF) testing provided on September 16, 2019.
You asked the Plan to pay for the testing services. You say that intraoperative neuromonitoring was ordered due to the potential risk the fusion procedure poses to the neurological system. The Plan denied your request. The Plan says the cost is included in the cost of the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that services integral to accomplishing a procedure are considered bundled into that procedure.
We looked at the file and the rules. The documentation shows the train of four testing was provided as part of intraoperative neuromonitoring services. The train of four testing is considered a component part of the intraoperative neuromonitoring. Therefore, we decided that the Plan does not have to pay for the train of four (TOF) testing provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services on November 22, 2019 to November 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the rendering provider and facility are both out-of-network.
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 for skilled nursing services on November 22, 2019 to November 29, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided December 9 to December 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says that the enrollee did not require inpatient level care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the records, the admitting physician could have reasonably expected that the enrollee's care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided December 9 to December 12, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery services provided on December 8, 2019
by an out of network (OON) provider.
You asked the Plan to pay for outpatient surgery services. You say that you depend on the hospital to verify
eligibility and to obtained proper authorization. The Plan denied your request. The Plan says no prior
authorization was 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 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 outpatient surgery services provided on December
8, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (99309) provided on December 10, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were plan providers available.
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 service 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 outpatient mental health services (99309) provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87653 provided on December 31, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 87653 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique.We find that CPT code 87653 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87653 provided on December 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 15, 2019 to November 17, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
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 August 7, 2019 to November 14, 2019. 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 pay for the skilled nursing services provided from November 15, 2019 to November 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Lite test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the preferred brand is not accurate. The Plan denied your request. The Plan says there is no medical reason documented that you are medically unable to use the Plan preferred test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion. You say that you need a second opinion for treatment. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the specialist services you received on January 20, 2020, and January 23, 2020.You asked the Plan to waive the copays for the services provided. You say that the provider was supposed to check your ears and discuss placing tubes.The Plan denied your request. The Plan says the claims were processed correctly according to your 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). Your contract with the Plan clearly says that you must pay a $40 copay for each specialist visit. The file shows that care was provided on each date of service provided. Your plan says that you pay a copay each time you receive certain medical services. You have been asked to pay a $40 copay for each date of service. The services fall within the physician 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 copays for the specialist services you received on January 20, 2020, and January 23, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the requested device. You say that the data from the device is used for heart failure management. The Plan denied your request. The Plan says the device is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The requested device is considered investigational and non-covered. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you need orthotics in order to walk appropriately.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation of a ventricular assist device in person, with physician or other qualified health care professional analysis(VAD) (93750) and the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on July 15, 2019.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.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 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 interrogation of a ventricular assist device in person, with physician or other qualified health care professional analysis (VAD) (93750) and the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on July 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and a MRI to be provided out-of-network.
You asked the Plan to pre-approve an office visit and a MRI. You say that laser ablation is the most attractive option to treat your prostate cancer and you cannot find a provider within the area that is in-network that can provide this treatment. You say that the facility has accepted you for a clinical trial and you would like the Plan to make an exception to provide coverage for an office visit and a MRI. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the office visit and a MRI out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet mulidirectional light therapy system for the enrollee.
You asked the Plan to pre-approve these services. You say that other treatment modalities for dermatitis would be more costly and have more side effects. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare covers UV light therapy for patients with generalized intractable psoriasis. We looked at the file and Medicare rules. The file shows that the enrollee does not have a diagnosis of generalized intractable psoriasis. 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 pre-approve an ultraviolet mulidirectional light therapy system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three retainer crowns (D6750 x3) and three pontics (D6240 x3).
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee previously had a bridge in this area that came off and cannot be recemented back in place. You also say that the enrollee would like to have another bridge placed in this area. The Plan denied your request. The Plan says these procedures are not listed as covered by the enrollee's plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three retainer crowns (D6750 x3) and three pontics (D6240 x3).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 21, 2019.You asked the Plan to pay for these 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 for the drug testing rendered on November 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital stays on October 30 and December 19, 2019.
You asked the Plan to waive the copayment for the inpatient stays. You say that the copayments should be waived because you did not stay overnight. The Plan denied your request. The Plan says the claims were billed at the inpatient level. The services were provided in an inpatient setting so the correct copayment was applied.
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 $200 copayment per day for days 1 through 4 for inpatient hospital care. You have been asked to pay two $200 copayments for two days of inpatient care. 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 inpatient hospital stays on October 30 and December 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BLS non-emergency ambulance A0428 x7 ground mileage A0425 x7 and BLS disposable supplies A0382 x7.
You asked the Plan to pre-approve the ambulance services. You say that you would like to appeal the denied services. The Plan denied your request. The Plan says the records do no show why all 10 requested trips are medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 the ambulance services. Our reviewer says that the provided medical records do not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) will be contraindicated for this enrollee on a future date, does not support that the enrollee needs the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on a future date and does not support that the ambulance transport on a future date will be medically reasonable and necessary. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pre-approve BLS non-emergency ambulance A0428 x7 ground mileage A0425 x7 and BLS disposable supplies A0382 x7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that a power seat elevation feature is medically necessary to reach a higher level of independence. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. A power seat elevation feature does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 12, 2019.
You asked the Plan to pay for these 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 for the drug testing rendered on December 12, 2019.