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

We decided that the Plan does not have to pay for acupuncture from October 7, 2019 through November 20, 2019 by an out-of-network provider.
You asked the Plan to pay for acupuncture. You say that you were aware your referral had expired. The Plan denied your request. The Plan says you were informed the referral expires on September 30, 2019.
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. There is no record that a Plan physician authorized the services you received. The services you received were not authorized and non-emergent or urgently needed while you were in the Plan's service area. Per your EOC, acupuncture care is covered for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain. You were informed the referral expires on September 30, 2019. The claims do not meet the Plan's or Medicare criteria for coverage of out-of-network care. You self-referred out-of- network. Therefore, we decided that the Plan does not have to pay for acupuncture from October 7, 2019 through November 20, 2019 by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide visits.

You asked the Plan to pre-approve home health aide visits. You say that you are not able to drive and need this nurse to go to your house. The Plan denied your request. The Plan says the denial of authorization for home health care is correct. The Plan also says that they have approved 7 of the 12 requested visits, therefore this denial is only for the remaining 5 visits.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health aide visits. Our reviewer says that you do not meet the Medicare criteria for the requested home health services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you beyond what was already approved by the Plan. There are no complex wounds, intravenous medications, new enteral feedings, or other skilled nursing needs. Your functional level does not require ongoing skilled therapy services to effectively provide treatment, care, and/or services which are medically necessary beyond what was already approved by the Plan. Without a need for skilled nursing or skilled therapy the request for a home health aide does not meet Medicare criteria and 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 home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on September 20, 2019.
You asked the Plan to pay for the physician's services. You say that you believed that this provider was in-network and that the Plan had approved these services. The Plan denied your request. The Plan says prior authorization and referral is required for specialist 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 contract with the Plan also says that prior authorization and referral is required for specialist services. The requested provider in this case is not a network provider with the Plan. 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 physician's services provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair seat elevation system, attendant control, expandable controller upgrade, electrical connection, and harness upgrade.
You asked the Plan to pre-approve power wheelchair accessories. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these devices is correct, because the power seat elevation system and attendant control are statutorily excluded from Medicare coverage and the remaining accessories are not medically necessary. The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature, an attendant control is non-covered if provided in addition to a beneficiary-operated drive control system, and other wheelchair accessories may be covered when they 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 power wheelchair accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested power wheelchair accessories. Our physician reviewer found the power elevating seat option is not a covered item as it is considered not primarily medical in nature. The enrollee has functional use of his left upper extremity which would enable him to activate the additional features of his wheelchair without use of an expandable controller upgrade and associated items being requested. There would be no need for an attendant control system. Therefore, the requested accessories are not 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 power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair seat elevation system, attendant control, expandable controller upgrade, electrical connection, and harness upgrade.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZioptan eye drops for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this drug is not covered under Part B.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-approveZioptan eye drops for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers PartD 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 nurse practitioner services provided on October 28, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 nurse practitioner services provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 18, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 laboratory 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 laboratory services provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with interpretation (D0364) provided on October 15, 2019.You asked the Plan to pay for the dental service. You say that a plan representative advised you were covered for a partial x-ray, but not a full mouth x-ray. You say that you asked someone in radiology prior to receiving the x-ray if it was a full mouth x-ray. You say that they advised it was not a full mouth x-ray.The Plan denied your request. The Plan says the cone beam CT capture with interpretation 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 cone beam CT capture with interpretation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with interpretation (D0364) provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 26,2019 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the provided services were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider from September 18, 2019, to October 8, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exceptionthat would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider from September 18, 2019, to October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOlopatadine HCL eye drops for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this is not covered under Part B.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 thetypes which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveOlopatadine HCL eye drops for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio (Q5101).
You asked the Plan to pre-approve Zarxio. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Zarxio. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Neupogen (filgrastim) and/or Nivestym (filgrastim-aafi) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio (Q5101).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on July 17, 2019.You asked the Plan to pay forunlisted neurological or neuromuscular diagnostic procedure. 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 separately 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.In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that train of four testing was completed. This service is considered integral to the primary procedure, therefore, is part of a bundled payment. Based on this information, we decided thatMedicare rules for coverage of unlisted neurological or neuromuscular diagnostic procedure have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for pathology services. You say that you would like appeal reprocessed and approved for payment.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 pathology services provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 17, 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 to the enrollee on September 17, 2019.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to getcare from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services rendered to enrollee on October 14, 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 the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that modifier "-22" should only be reported with procedure codes that have a global period of 0, 10, or 90 days. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 00142 with modifier -22. This code does not have a global surgical period; therefore, the use of modifier -22 is not allowed.Therefore, we decided that the Plan does not have to pay forthe anesthesia services rendered to enrollee on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on November 1, 2019 by an out of network provider. You asked the Plan to pay for the dental services. You say that you spoke to a plan representative that advised the provider's contract expired on December 22, 2018. You say that the enrollee was never advised of this change at the time of service. The Plan denied your request. The Plan says dental services must be received from an in network provider in order to be covered. The Plan says the provider in this case is not a network provider with the dental vendor. The Plan also says dental services received out of network are not covered. 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 and oral exams and prophylaxis are covered services, they are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on November 1, 2019 by an out of network provider.