Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 14, 2020, by an
OON provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician.
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 had network providers
available who could have provided 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 physician services provided on October 14, 2020,
by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show the enrollee requires daily skilled nursing or daily rehab care at the SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the occupational therapy provided on January 8, 2021 and January 12, 2021 and the finger orthosis provided on January 12, 2021.

You asked the Plan to waive the cost for the occupational therapy and finger orthosis. You say that you suffer from trigger thumb and your doctor agreed that therapy can help. You say that the decision should be reconsidered. The Plan denied your request. The Plan says the cost share applied correctly.

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 $40 per day for Medicare-covered occupational therapy services from an in-network provider and 20% for Medicare-covered equipment and supplies from an in-network provider. 

You have been asked to pay a total of $118.99 for the occupational therapy and finger orthosis.

The occupational therapy falls within the "Outpatient rehabilitation services" benefit category. The finger orthosis falls within the "Durable medical equipment (DME) and related supplies" 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 cost for the occupational therapy provided on January 8, 2021 and January 12, 2021 and the finger orthosis provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network
dentist.
You asked the Plan to pre-approve dental services. You say that this provider has already treated you, and you
do not understand why the Plan is now saying the provider is out-of-network. The Plan denied your request.
The Plan says the denial of authorization for these services is correct, because dental services are only covered
when obtained from participating dental providers.
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 for an out-of-network provider. Therefore, we decided that the Plan
does not have to pre-approve dental services to be provided by an out-of-network dentist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are not physically ready to go home and cannot take care by yourself independently. The Plan denied your request. The Plan says that there are no skilled nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are needed to regain strength to get
back to a baseline function. The Plan denied your request. The Plan says that the enrollee can safely receive the
services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for alcohol intoxication
and was treated for alcohol withdrawal and COPD. The enrollee's medical problems are stable. There are no
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the
medical record supports a need for physical and/or occupational therapy, there is no documented need for
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is
not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotic equipment provided December 8, 2020.

You asked the Plan to pay for the orthotic equipment. You say that you would like these claims reconsidered
for medical necessity. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the member and the ordering physician.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. Specifically, the medical records do not provide an adequate history of the enrollee's medical
condition necessitating the need for the provided services. The record shows that the Plan made several
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not
have to pay for the orthotic equipment provided December 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you have stabilized medically and have been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. Although you have made slow progress with therapy, your functional improvement has plateaued, and there is no indication that a transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on September 15, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis. You say that you were told that this provider was in-network. The Plan denied your request. The Plan says no benefits are available for procedures performed by OON providers.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on September 15, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 15, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the laboratory services have not been met. Specifically, the submitted claim was billed with a
laboratory place of service code while the record indicates that the member's face-to-face service was rendered
in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on October 8, 2019.

You asked the Plan to pay for the denture. You say that you had issues reaching the enrollee's primary insurance provider after the service. The Plan denied your request. The Plan says this claim was not filed within one year of the date of service.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the denture was not filed until December 29, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the partial lower denture (D5214) provided on October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on June 4, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the partial foot shoe insert (L5000) provided September 3, 2020.
You asked the Plan to pay for the partial foot shoe insert. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that the item was provided within the reasonable useful lifetime for this equipment.
The Plan must follow Medicare rules. Medicare rules say that coverage for shoe inserts is allowed once per calendar year. We looked at the file and Medicare rules. The file indicates that although the Plan is arguing there is a 5-year reasonable usefulness lifetime, the Plan contract specifically says that diabetic shoe inserts are available once every calendar year. Based on this information, we decided that Medicare rules for coverage of the partial foot shoe insert have been met. Therefore, we decided that the Plan has to pay for the partial foot shoe insert (L5000) provided September 3, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Covid-19 testing (U0004) provided on June 22, 2020.

You asked the Plan to pay for Covid-19 testing. You say that this should be covered. The Plan denied your
request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The service at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of Covid-19 testing have not been met. Therefore, we decided that the
Plan does not have to pay for Covid-19 testing (U0004) provided on June 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on September 29, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollees Evidence of Coverage.

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 physical therapy services. 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 physical therapy services provided on
September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the records do not show cancer marker programmed death-ligand 1 (PD-L1) on members cancer cells.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the use of this drug is not indicated per FDA guidelines or Medicare approved compendia. Our physician reviewer found per the compendia, Keytruda cannot be approved for recurrent disease unless PD-L1 is positive in the member's cancer cells. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Colpopexy procedure (57288, 57285, 57282, 52000).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not indicate that this patient has significant prolapse symptoms. The records also indicate that she has not tried behavior modification, pelvic floor exercises, or medical therapy for urge incontinence. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Colpopexy procedure (57288, 57285, 57282, 52000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions (D7210 x2), removal of an impacted
tooth (D7240), first 15 minutes of deep sedation/general anesthesia (D9222), three subsequent 15 minute
increments of deep sedation/general anesthesia (D9223 x3), and three adjunctive procedures (D9999 x3)
provided on December 10, 2019.
You asked the Plan to pay for the extractions, removal of an impacted tooth, deep sedation/general anesthesia
services, and adjunctive procedures. You say that these services were medically necessary. The Plan denied
your request. The Plan says these services are not covered benefits under your dental 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 pay for the two
extractions (D7210 x2), removal of an impacted tooth (D7240), first 15 minutes of deep sedation/general
anesthesia (D9222), three subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x3),
and three adjunctive procedures (D9999 x3) provided on December 10, 2019.