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

We decided that the Plan does not have to pre-approve echocardiography (93307).
You asked the Plan to pre-approve the echocardiography. You say that you are having trouble breathing, headaches and stomach problems. The Plan denied your request. The Plan says the documentation does not show the results of the myocardial perfusion imaging that was previously approved and does not indicate why repeat TTE is needed.
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 echocardiography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you had normal left ventricular ejection fraction on an echocardiogram after a recent Non-ST-elevation myocardial infarction with no documented subsequent clinical cardiac change or abnormal cardiac physical exam. 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 echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve echocardiography (93307).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on February 26, 2019 by the out of network provider.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent and were not preauthorized.
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 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 for the outpatient mental health services provided on February 26, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of skin and/or muscle (11043) provided on September 16, 2019
You asked the Plan to pay for removal of skin and/or muscle. You say that medically necessary services were provided on the request of the Medical Director. Emergency wound care was provided in the absence of another contracted wound care physician to avoid delay in care which could have resulted in complications, infection and/or hospitalization. You have attached medical documentation supporting the need for the services. The Plan denied your request. The Plan says non-urgent services were not authorized because the physician is a non-network provider with the member's health plan, and 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 removal of skin and/or muscle (11043) provided on September 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 1, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was just a meet and greet. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $20 copayment for physician/practitioner services/primary care doctor visit. You have been asked to pay a $20 copayment for an office visit. Since an office visit occurred, the correct copayment has been applied. An office visit falls within the physician/practitioner services/primary care doctor visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on August 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that inpatient rehab is best for right now. The Plan denied your request. The Plan says the enrollee does not require a doctor visit at least 3 times per week.
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 you are at moderate assist for lower body dressing, toileting, and transfers. You are at supervision for eating, grooming, and upper body dressing. You are at minimal assist for transfers. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The documentation does not reveal that your renal function has stabilized yet. Transfer to a rehabilitation facility is not appropriate until acute medical issues have been stabilized or improving. You may benefit and participate in additional physical and occupational therapy, but your functional status does not require this on an intensive rehabilitation facility therapy program 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a pelvic ultrasound (76856) provided on July 8, 2019.
You asked the Plan to pay for a pelvic ultrasound. You say that the enrollee should have annual ultrasounds due to her family history. The Plan denied your request. The Plan says this was a screening test and therefore is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a pelvic ultrasound, was requested solely for screening purposes, as evidenced by the billing of diagnosis code Z12.73: Encounter for screening for malignant neoplasm of ovary. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a pelvic ultrasound (76856) provided on July 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Rexulti 3mg tablets.You asked the Plan to pre-approvethe Rexulti tablets. You say that this drug is needed.The Plan denied your request. The Plansaysthe oral drug is not covered by Medicare 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 Plandoes not haveto pre-approveRexulti 3mg tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 3, 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 and the services were ordered by a non-planprovider.Medicare rules say that plans can requireenrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 thiscase 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 topay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on September 3, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on December 18, 2018.You asked the Plan to pay for this 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 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 for services provided on December 18, 2018
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 27, 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 procedures must be performed by the contract laboratory
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 lab services provided to the enrollee on August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from June 17, 2019 through June 26, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that thePlan has to pay forthe acute inpatient hospital care provided from June 17, 2019 through June 26, 2019.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) of the spine provided during an inpatient stay on September 4, 2019.You asked the Plan to pay for an MRI provided during an inpatient stay. You say that this was medically necessary.The Plan denied your request. The Plan says this service was provided without authorization.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
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 an MRI provided during an inpatient stay. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation supports that the enrollee was stable for transfer on August 29, 2019 at 6:35 AM. At that time, there was no evidence of acute coronary syndrome, the enrollee's condition had not deteriorated, and he was ambulatory with a cane. The plan was for analgesia, physical/occupational therapy, an MRI of the spine, and a neurosurgery consult.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI provided during an inpatient stay have not been met.Therefore, we decided that the Plan does not have to pay formagnetic resonance imaging (MRI) of the spine provided during an inpatient stay on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a chest wall respiratory sensor electrode.
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 a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CPT 0466T is not a covered code. Medicare does not consider CPT 0466T to be medically necessary. As it is not covered, the related code CPT 64568 also cannot be covered. 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 insertion of a chest wall respiratory sensor electrode.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided out of network from August 14, 2019 to August 26, 2019.
You asked the Plan to pay for out of network providers. You say that you have seen this provider for 30 years and this care should be covered. The Plan denied your request. The Plan says you 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 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 for chiropractic services provided out of network from August 14, 2019 to August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on February 12, 2019.
You asked the Plan to pay for this 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 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 services provided on February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor for "the enrollee". You asked the Plan to pre-approvethe requested items. You say that the enrollee would benefit from utilizing the sensor with her pump.The Plan denied your request. The Plan says there is no Medicare benefit for the requested items.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.The file shows that a disposable sensor (A9276) and external transmitter (A9277) was requested for the enrollee. We looked at the file, and Medicare rules. The requested items are used with non-therapeutic continuous glucose monitors. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor for "the enrollee".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a behavioral health inpatient stay.
You asked the Plan to pre-approve a behavioral health inpatient stay. 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. 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 a behavioral health inpatient stay. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 31, 2020 forward and could have been treated in a lesser restrictive 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 a behavioral health inpatient stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a behavioral health inpatient stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2751) for teeth #11 and 32 provided on July 9, 2019.
You asked the Plan to pay for the dental services. You say that the enrollee is already on a payment plan for a crown implants procedure. The Plan denied your request. The Plan says the frequency limit for the crowns has been exceeded.
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 crowns are a covered service, the frequency limit has been exceeded. The record shows that you last received a crown for tooth #11 on December 20, 2018 and was paid as a covered benefit. Additionally, you received a crown for tooth #32 on December 7, 2018 and was paid as a covered benefit. Therefore, we decided that the Plan does not have to pay for the crowns (D2751) for teeth # 11 and 32 provided on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.You asked the Plan to pre-approve a raised toilet seat. You say that you feel that this should be covered.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for monthly eye injections to be provided in Florida.You asked the Plan to pre-approve physician's services for monthly eye injections. You say that you have been receiving injections for macular degeneration and you will need these injections every four weeks whileyouare in Florida. The Plan denied your request. The Plan says when you are outside the service area and cannot get care from a network provider, the Plan will cover urgently needed services that you can get from any provider.Urgently needed services are defined as non-emergency, unforeseen (unexpected) medical illness, injury or condition that requires immediate medical care.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at the file,Medicare rulesand the Plan's rules. The rules say that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan. The file shows that you have been receiving the eye injections for macular degeneration prior to going to Florida and this was not an unforeseen illness or condition. Therefore, we decided that the Plan does not have to pre-approve physician's services for monthly eye injections to be provided in Florida.