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

We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the ophthalmology services. You say that you are due for cataract surgery in both eyes and a MIGS procedure would help to reduce your glaucoma pressure. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. If an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan has confirmed there are providers in-network who are available to provide the requested treatment.
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 the ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the SNF care provided from May 11, 2019 to June 9, 2019.
You asked the Plan to pay for the SNF care. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee received custodial care while they remained at the facility. The Plan also says that no skilled nursing services were provided during this time.
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 SNF care. Our reviewer says that the enrollee met the Medicare criteria for SNF care. Our physician reviewer found the enrollee did have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for the SNF care provided from May 11, 2019 to June 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 16, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on October 16, 2019.
Appeal type: Practitioner Services
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 September 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 for the medical services provided to the enrollee by an out-of-network provider on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services, dietician consultation.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are requesting reconsideration for the denial of consultation and 3 follow up visits. The Plan denied your request. The Plan says the Medicare criteria for approval have not been met due to there being no diagnoses of renal disease or diabetes.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services, dietician consultation.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a biopsy and scraping of the cervix using an endoscope (57454) provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a biopsy and scraping of the cervix using an endoscope. You say that you want a review of the documents for date of service November 20, 2019. You are requesting reprocessing the claim for payment. The Plan denied your request. The Plan says this clinic is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health 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 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 a biopsy and scraping of the cervix using an endoscope (57454) provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior cervical fusion.
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that the records do not show that the enrollee had recent physical therapy. The records also do not show smoking cessation. The criteria for fusion are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior cervical fusion.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvean echocardiography (93307).You asked the Plan to pre-approvethe echocardiography. You say that this service is medically necessary.The Plan denied your request. The Plan says that there is no documentation of why the member needs an ultrasound of the heart.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the echocardiography. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found further evaluation of the murmur in a patient with increased cardiac risk is reasonable, appropriate and considered standard accepted practice in the medical community.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of the echocardiography have been met.Therefore, we decided that the Plan has to pre-approvean echocardiography (93307).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 22, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
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 the denied codes (CPT 80307 and HCPCS G0480) are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe outpatient office visit. You say that you have seen this doctor in the past with the issues regarding your vision and you feel most comfortable having the cataract surgery with him.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. If an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider.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-approvethe outpatient office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub (E1399).
You asked the Plan to pre-approve a walk-in tub. You say that you have a sliding shower bench but your current tub is too high and it is difficult getting in and out of the tub. You're using cleansing clothes right now because you cannot get in the tub. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in tub (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the surgery. You say that you would like reconsideration as you were unaware of the member's insurance. The Plan denied your request. The Plan says outpatient surgery requires pre-approval prior to rendering the service and the Plan requires the utilization of in network providers unless out of network services are pre-approved.
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 September 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nephrology services received from March 11, 2019 to April 1, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider is not in-network, and there is no authorization on file.
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 nephrology services received from March 11, 2019 to April 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay more for the infrared therapy services provided from April 8, 2019 to May 20, 2019.
You asked the Plan to pay more for the infrared therapy services. You say that you were not advised that you needed authorization to receive these services. The Plan denied your request. The Plan says the rendering provider is out-of-network with the Plan. The Plan also says that you have a 20% coinsurance amount with the POS benefit.
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 outpatient rehabilitation services. You have been asked to pay for the infrared therapy services. The infrared therapy services fall within the outpatient rehabilitation services 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 pay more for the infrared therapy services provided from April 8, 2019 to May 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 3, 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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no medical records have been submitted for review. Two PA forms, which provide conflicting information, have been submitted for review. Consequently, the documentation does not clearly and reliably establish that the enrollee is a diabetic, who uses the results of blood glucose testing to adjust and administer insulin, multiple times a day. Therefore, the requested CGM is not currently shown to be medically necessary or reasonable. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from March 15, 2019 to April 16, 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 the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
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 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 March 15, 2019 to April 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forostomy supplies provided from November 5, 2019 through December 6, 2019.You asked the Plan to waive the coinsurance forthe ostomy supplies. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plansays 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 showthat you received ostomy supplies provided from November 5, 2019 through December 6, 2019. You are asked to pay 20% coinsurance for the ostomy supplies. 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 forostomy supplies provided from November 5, 2019 through December 6, 2019.