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

We decided that the Plan does not have to pay for the ambulance services provided on December 3, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on December 3, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 3, 2020.
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 medically necessary. 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 coronary artery bypass grafting and aortic valve replacement. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for orthopedic services to be
provided by an OON provider.

You asked the Plan to pre-approve an in-network exception. You say that the enrollee has been seeing this
specialist since the beginning of the year. The Plan denied your request. The Plan says there are in-network
providers within a similar distance that can provide this service.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that this plan has a point of service (POS) option which allows you to get certain covered services
from out-of-network provider.

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 an exception for these services. Therefore, we decided that the Plan does not have to pre-approve
an in-network exception for orthopedic services to be provided by an 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 rendered from
December 18, 2020, to December 29, 2020.

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 the provider type is not covered.

The Plan must follow Medicare rules. The rules say that a marriage family therapist is not eligible to participate
in Medicare.

We looked at the file and Medicare rules. The file shows that the services were rendered by a marriage family
therapist. This provider is not covered by Medicare. Therefore, we decided that the Plan does not have to pay
for the outpatient mental health services rendered from December 18, 2020, to December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the follow-up visit provided on April 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the follow-up visit. You say that the service is medically necessary. 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 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 follow-up visit provided on April 23, 2020 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 outpatient visit on July 21, 2020.

You asked the Plan to pay for the outpatient visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says post-operative visits performed during the postoperative period of a global surgery that are related to the recovery from that surgery are included in the global surgical package.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -79 modifier if the service billed with the modifier indicates a distinct procedural service. 

Physicians who perform the surgery and furnish all of the usual pre- and postoperative work bill for the global package by entering the appropriate CPT code for the surgical procedure only. Billing is not allowed for visits or other services that are included in the global package. Payment for this procedure or post-operative visit was included in the surgical procedure payment. Therefore, we decided that the Plan does not have to pay for the outpatient visit on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says alternatives would be a fixed height or variable height hospital bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed 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 the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection services received on January
13, 2021.

You asked the Plan to waive the coinsurance for the injection services. You say that you feel like these services
should fall within the specialist office visit copayment. The Plan denied your request. The Plan says the claim
was processed per your plan 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 20%
coinsurance for Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the injection services. The injection services fall within the
Medicare Part B drugs 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 the
injection services received on January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on June 24, 2020.

You asked the Plan to waive the copayment for an ECG. You say that the ECG was part of your annual wellness exam and you disagree with the charges. 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 $30 copayment for non-radiological diagnostic services. 

You received an ECG on June 24, 2020. An ECG is not included in the annual wellness exam. Therefore, you are responsible to pay your share of the cost-sharing charges. 

You have been asked to pay the allowed amount of $14.97, which is less than the $30 copayment for an ECG. An ECG falls within the outpatient diagnostic tests and therapeutic service and 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 copayment for an ECG provided on June 24, 2020.
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 medically necessary. 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 congestive heart failure. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 200-unit Tresiba FlexTouch.

You asked the Plan to pre-approve the Tresiba FlexTouch. You say that you would like reconsideration
because this drug is medically necessary. The Plan denied your request. The Plan says this medication does not
fall under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 the 200-unit Tresiba
FlexTouch.

Benefits for the Tresiba FlexTouch may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term care services.

You asked the Plan to pre-approve the long-term care services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services at issue are custodial in nature. Custodial care is not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the long-term care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve long-term care services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility SNF services after February 23, 2021.

You asked the Plan to pre-approve continuation of SNF services after February 23, 2021. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for daily skilled rehabilitation or skilled nursing services.

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 continuation of SNF services after February 23, 2021. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at minimal to maximal assist with transfers (or mechanical lift). The enrollee required varying assist with activities of daily living. He tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services after February 23, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services after February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on November 12, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you think that the charges are unfair and you cannot afford them. 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 $100 copayment for each radiological diagnostic service. 

You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a CT scan provided on November 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan and MRI provided on September 30, 2020.

You asked the Plan to waive the copayment for the CT scan and MRI. You say that you were not notified about the copayment for radiology. The Plan denied your request. The Plan says the copayments 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 a $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at a free-standing facility (such as a radiology center or medical clinic). 

You have been asked to pay a $160 copayment for the CT scan and a $160 copayment for the MRI. The CT scan and MRI fall within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for the CT scan and MRI provided on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial mastectomy services coded 19301 provided on November 3, 2020.

You asked the Plan to pay for the partial mastectomy 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 payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 19301 is not supported in the medical record. Specifically, this code was billed with modifier 79 (unrelated procedure or service by the same physician during the postoperative period). This service was not billed with a 0, 10, or 90 day post-operative procedure. Based on this information, we decided that Medicare rules for coverage of the partial mastectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the partial mastectomy services coded 19301 provided on November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive cardiovascular genetic testing (81286, 81404, 81407, 81408, 81479) provided on September 28, 2020.

You asked the Plan to pay for comprehensive cardiovascular genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of comprehensive cardiovascular genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive cardiovascular genetic testing (81286, 81404, 81407, 81408, 81479) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for biologic materials to aid soft tissue (D4265 x 2) provided on October 20, 2020.

You asked the Plan to reimburse you for the dental service. You say that you paid $100 out of pocket for the services. You say that you feel you should be reimbursed for these services. The Plan denied your request. The Plan says biologic materials to aid soft tissue is not listed as a covered service.

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 reimburse you for biologic materials to aid soft tissue (D4265 x 2) provided on October 20, 2020.