Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each (CPT Code L3000) provided on June 10, 2019.You asked the Plan to pay forfoot orthotics. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay forfoot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each (CPT Code L3000) provided on June 10, 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on June 13, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that you confirmed the member's benefits and believe that non-emergency transport is a covered benefit if medical necessity is met. The Plan denied your request. The Plan says they have no record of the non-participating provider calling to verify member benefits and coverage.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for non-emergent ambulance services. Our physician reviewer found the documentation does not support that the ambulance transport on June 13, 2019 was medically reasonable and necessary for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on June 13, 2019.
Appeal type: Lab
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 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for the 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 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 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that no other plan for the enrollee would be beneficial. The Plan denied your request. The Plan says ongoing skilled services can be provided on an intermittent basis.
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 physician reviewer found that the enrollee was admitted to acute care after falling at home. The enrollee's medical conditions appear stable. There are no wound care needs. He does not require medical oversight of his condition at an acute hospital level of care. He is ambulating greater than household distances and does not require an intensive rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition compared with therapy provided at a less intense level. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that the skilled nursing facility is responsible to obtain any authorization that is needed. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 skilled nursing services provided on August 28, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a creatinine test (82565) and a computed tomography (CT) scan (70470) provided on October 16, 2019.
You asked the Plan to waive the copayment for a creatinine test and a CT scan. You say that you were not informed of these copayments when you got approval for these services. The Plan denied your request. The Plan says these services processed 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 $5 copayment for diagnostic lab services and a $275 copayment for each advanced imaging service. You have been asked to pay $5 for a creatinine test, which is a diagnostic lab service and $275 for a CT scan, which is an advanced imaging service. 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 creatinine test (82565) and a computed tomography (CT) scan (70470) provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe initial 15 minutes of sedation (D9222) and the additional 15 minutes of sedation (D9223).You asked the Plan to pre-approvethe dental services. You say that you were advised that anesthesia is not a covered service by the Plan. You say that you could not have your teeth pulled in 2019 because of the anxiety attacks that you had in the dental chair.The Plan denied your request. The Plan says sedation is not 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 thePlan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe initial 15 minutes of sedation (D9222) and the additional 15 minutes of sedation (D9223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe tissue exams provided on August 27, 2019, September 26, 2019 and October 8, 2019.You asked the Plan to waive the copayment forthe tissue exams. You say that you do not understand the charges. You say that your Plan says $35 per day per provider.The Plan denied your request. The Plan says the copayments applied correctly.The rules saya 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 $35 per day, per in-network provider, or Medicare-covered pathology services.You have been asked to pay a total of $84.57 for the tissue exams. The tissue exams fallwithin 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 forthe tissue exams provided on August 27, 2019, September 26, 2019 and October 8, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora total knee arthroplasty (27447) provided on August 5, 2018.You asked the Plan to pay for the total knee arthroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the total knee arthroplasty have not been met. Specifically, there is insufficient information to determine whether payment is due and the amount of payment. The record submitted does not include documentation of a total knee arthroplasty. Therefore, we decided that the Plan does not have to pay for a total knee arthroplasty (27447) provided on August 5, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic blood pressure monitor (A4670) provided August 15, 2019.
You asked the Plan to pay for automatic blood pressure monitor. You say that this was a return trip after dialysis that renders patients very week with increased decrease in mobility. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pay for automatic blood pressure monitor (A4670) provided August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for wound closure (13160) provided on August 26, 2019.
You asked the Plan to pay for the wound closure. You say that you would like reconsideration as the CPT code billed is payable to the assistant surgeon. The Plan denied your request. The Plan says Medicare claim payment guidelines say that there will be no payment for assistants at surgery for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 13160. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the wound closure have not been met. Therefore, we decided that the Plan does not have to pay for wound closure (13160) provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and electrocardiogram (93000) provided on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit and electrocardiogram. You say that these services should be reprocessed for payment.The Plan denied your request. The Plan says these 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 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 office visit (99214) and electrocardiogram (93000) provided on September 19, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LINX reflux management system.You asked the Plan to pre-approve LINX reflux management system. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must followMedicare rules. Medicare rules say that the LINX reflux management system is non-covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LINX reflux management system have not been met.Therefore, we decided that the Plan does not have to pre-approve LINX reflux management system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections.
You asked the Plan to pre-approve the Hyalgan injections. You say that this is needed. The Plan denied your request. The Plan says there is no x-ray confirmed diagnosis of knee arthritis.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation of the knee is covered when there is radiological evidence of osteoarthritis. 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 Hyalgan injections. Our reviewer says that the requested injection is not medically necessary. Our physician reviewer found the record does not contain any radiology findings of knee arthritis. 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 Hyalgan injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that SNF care would be the best option. The Plan denied your request. The Plan says the enrollee is not medically stable to leave the current facility.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is currently unable to safely participate in care at the SNF level. He is considered at high risk of decompensation and has been unable to wean from ventilatory support. He is being monitored via telemetry for supraventricular tachycardia. LTAC care remains the appropriate level of care. SNF level care is not appropriate at this time. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodic oral evaluations, two prophylaxes, and
bitewings provided on April 18, 2019 and October 24, 2019.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that you have
seen this dentist for years. You also say that this provider takes excellent care of your teeth. The Plan denied
your request. The Plan says these services are denied because this dentist is an out-of-network provider.
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 out-of-network. Therefore, we decided that the Plan does not have to pay for
the two periodic oral evaluations, two prophylaxes, and bitewings provided on April 18, 2019 and October 24,
2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 4, 2019 to September 2, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says clinically the enrollee's condition no longer required daily skilled services at an inpatient 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 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 4, 2019 to September 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on June 27, 2019.
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says that 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 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 genetic testing provided on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe portable power wheelchair purchased on August 29, 2019 from OON provide.You asked the Plan to reimburse you forthe portable power wheelchair. You say that the enrollee needed a power wheelchair totransportin and out of the car so you shopped around.The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network supplier.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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.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. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover power mobility devicesfor use only outside the home. We found no exception that would require the Plan to reimburse you for these items.Therefore, we decided that the Plan does not have to reimburse you forthe Air Hawk portable power wheelchair and accessories purchased on August 29, 2019 from OON provider.