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

We decided that the Plan does not have to pay for outpatient lab work provided on April 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these lab 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 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 lab work provided on April 6, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Synvisc-One injections for both knees.
You asked the Plan to pre-approve Synvisc-One injections. You say that the enrollee could benefit from injections. The Plan denied your request. The Plan says that there is no record of the enrollee trying physical therapy, conservative therapy, or over-the-counter pain relievers.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 Synvisc-One injections. Our reviewer says that the enrollee has a history of bilateral knee pain. The enrollee is status post left knee arthroscopy in 2003. The enrollee reported that corticosteroid injection at the last visit did not help. Based on the enrollee's symptoms and lack of improvement after cortisone injection, the enrollee could potentially benefit from Synvisc-One injections for both knees. Our physician reviewer found evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Current evidence based medical guidelines state that medical evidence suggests that intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. A trial of Synvisc-One injections is reasonably indicated for treatment of this enrollee's knee pain given the failure of reasonable conservative treatment. Therefore, the documentation would support that the Synvisc-One injections are medically reasonable and necessary and safe and effective for treatment of this enrollee's bilateral knee osteoarthritis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One injections have been met. Therefore, we decided that the Plan has to pre-approve Synvisc-One injections for both knees.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that the location is an hour and twenty minutes' drive from your home.The Plan denied your request. The Plan says this provider is 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 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 referral to an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approvethe admission. You say that this is medically necessary.The Plan denied your request. The Plan says there are no skilled therapy or 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 above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee is at a high functional level that does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Automatic Blood Pressure Cuff.You asked the Plan to pre-approve an Automatic Blood Pressure Cuff. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Automatic Blood Pressure Cuffs are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approve an Automatic Blood Pressure Cuff.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve retainer crowns for tooth #'s 2 & 4 and a pontic for tooth #3.
You asked the Plan to pre-approve the retainer crowns and pontic. You say that a bridge is recommended to restore tooth #2 and the missing space on tooth #3. The Plan denied your request. The Plan says that the documents fail to demonstrate a specific medical condition that would preclude the use of a removable partial denture. The Plan also says that the documentation does not support a crown for tooth #19 because the tooth does not appear to have significant breakdown.
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. The Plan covers the retainer crowns and pontic when the services are medically necessary and reasonable. 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 retainer crowns and pontic. Our reviewer says that these services meet the criteria for coverage. Our physician reviewer found tooth #3 is the only missing functional tooth in the arch. Our reviewer found that teeth #'s 2 and 4 have good bone support and would serve well as abutment retainers for a fixed bridge replacing tooth #3. There is no indication in the EOC that a removable partial had to be used instead of a fixed bridge. Our physician reviewer also found that replacing a single posterior tooth with a removable partial denture is not reasonable when the prognosis for a fixed bridge or implant is good, as in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontic have been met. Therefore, we decided that the Plan has to pre-approve retainer crowns for tooth #'s 2 & 4 and a pontic for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for gadoterate meglumine injections (A9575x110) provided on September 19, 2019. You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support that gadoterate meglumine, 0.1 ml was administered. 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 A9575x110 is injection, gadoterate meglumine, 0.1 ml. We asked our coder 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 injections. Our reviewer says that CPT code A9575x110 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of an injection, gadoterate meglumine, 0.1 ml (110 units) being administered on September 19, 2019, therefore this service cannot be validated. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for gadoterate meglumine injections (A9575x110) provided on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSaxendra.You asked the Plan to pre-approveSaxendra. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Saxendra is not covered under the enrollee's Medicare Part B 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-approveSaxendra.Benefits for Saxendramay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter procedure provided to the enrollee on November 12, 2019.
You asked the Plan to pay for the services provided. You say that the code was billed for the safari foreign body technique provided. The Plan denied your request. The Plan says the billed code is not substantiated by the clinical 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 37197 is transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed. 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 services provided. Our physician reviewer found that the documentation does not support the service as billed. Code 37197 applies to retrieval of a completely intravascular foreign body that requires removal and includes all imaging guidance through fluoroscopy and ultrasound, radiologic supervision and interpretation, and moderate sedation. Intravascular ultrasound is bundled into this code as is ultrasound guidance for access. As the wire that was snared was still largely extravascular and could easily have just simply been pulled out to remove, the code for removal of a retained intravascular device does not apply. 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the transcatheter procedure provided to the enrollee on November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSpravato.You asked the Plan to pre-approveSpravato. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Spravato is not covered by the enrollee's Medicare Part B 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-approveSpravato.Benefits for Spravatomay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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.You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services. The enrollee's care needs can be met at a lower level of 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on November 20, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 providersavailable 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 items/services.Therefore, we decided that the Plan does not have to pay forout of network physician services provided to the enrollee on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services rendered to on August 19, 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 the services were rendered by a CRNA and were notbilled correctly.The Plan must follow Medicare rules. The rules say that anesthesia services provided by a CRNA must be billed with the QZ modifier.We looked at the file and Medicare rules. The file shows that the services were not billed with the required modifier to signify that the services were performed by a CRNA. 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 anesthesia services rendered on August 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services (S9122), the nursing care in the home provided by a registered nurse (S9123), and the occupational therapy (S9129) provided October 28, 2019 to October 30, 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 that 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. Your organization 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 home health aide services (S9122), the nursing care in the home provided by a registered nurse (S9123), and the occupational therapy (S9129) provided October 28, 2019 to October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee on September 20, 2019.You asked the Plan to pay forthis claim. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 servicesat 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 forout of network physician services provided to the enrollee on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic care provided to the enrollee from November 6, 2019 to November 27, 2019.You asked the Plan to pay forthis service. You say that these claims should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 hasnetwork 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 forout of network chiropractic care provided to the enrollee from November 6, 2019 to November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician visit. You say that the enrollee has no choice in the providers they are seen by while in the facility.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 and prior authorization was not 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 the medical services provided on November 21, 2019 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 8, 2019 through January 11, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are on limited income. 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). Review of the file shows that you were admitted on January 8, 2019 and discharged on January 11, 2019. You were asked to pay a $335 copayment per day from January 8, 2019 through January 10, 2019, days 1-3 of your inpatient hospital care. You were discharged on January 11, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $335 copayment per day required for days 1-5. 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 care from January 8, 2019 through January 11, 2019.