Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on May 5, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reconsidered for reimbursement. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit (99214) provided on May 5, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's needs can be met in a lower level of care setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital and when considered medically stable by the 
treating team will be an appropriate candidate for care at a less intense level. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on July 21, 2020. 
 
You asked the Plan to pay for the outpatient hospital 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 outpatient hospital services provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the vision exam you had on September 28, 
2018, and the MRI you had on July 2, 2019. 
 
You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 $40 
copayment for each exam to diagnose and treat diseases and conditions of the eye. Your contract also says that 
you must pay a $250 copayment for each advanced imaging service. 
 
Review of the file shows that you had a vision exam on September 28, 2018, and an MRI on July 2, 2019. You 
have been asked to pay a $40 copayment for the vision exam. The exam falls within the vision care benefit 
category. The allowed amount for the MRI was $247.58. Since the allowed amount was less than the $250 
copayment required by your Plan contract, you have been asked to pay the lesser amount. 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 cost share for the vision exam you had on 
September 28, 2018, and the MRI you had on July 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forphysical therapy provided from June 2, 2020 through June 30, 2020.You asked the Plan to waive the copayments forphysical therapy. You say that you were informed you wouldn't be charged. You say that you wouldn't have done therapy if you weren't misinformed and the charge should be removed.The Plan denied your request. The Plan says the copayments applied 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 $40 copayment for physical therapy from an in-network specialist's office, outpatient hospital or comprehensive outpatient rehab facility. You have been asked to pay a $40copayment for each physical therapy visit. The total amount you owe is $240 ($40/visit x 6 visits = $240). Physical therapy falls 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 waive the copayments forphysical therapy provided from June 2, 2020 through June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 2 surgical extractions (D7210) provided on 
August 3, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you were aware that surgical 
extractions would not be covered. You also say that you believe that the services were not billed correctly. The 
Plan denied your request. The Plan says surgical extractions are 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 requested items or services are not 
among those covered under this benefit. The record shows that the Plan contacted the provider and confirmed 
that surgical extractions were in fact performed on the date of service. Therefore, we decided that the Plan does 
not have to reimburse you for the 2 surgical extractions (D7210) provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 27, 2020, by a provider that 
has opted out of Medicare. 
 
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the provider does not participate with Medicare and has 
opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the services provided on May 27, 2020, by a provider that has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the implantable cardiac defibrillator (ICD) 
surgery you had on May 12, 2020 to May 13, 2020. 
 
You asked the Plan to waive the copayment for the ICD surgery. You say that you were kept overnight, so this 
copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment 
correctly because you were never admitted to the hospital. 
 
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 $150 
copayment for surgery in an outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for the ICD surgery. Records show that although you stayed 
overnight in the hospital, you were never formally admitted as an inpatient.  That is why the ICD surgery falls 
within the surgery in an outpatient hospital facility 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 the implantable cardiac defibrillator (ICD) surgery you had on May 12, 2020 to May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesprovidedon June 19, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the facility.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 thePlan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's servicesprovidedonJune 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 6, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (U0003) provided on June 10, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 laboratory services (U0003) provided on June 
10, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe denture reline (D5751) provided on June 15, 2020.You asked the Plan to pay forthe dental service. You say that your denture was too big and was creating sores on your gums. You say that you thought this would be covered.The Plan denied your request. The Plan says denture reline 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 denture reline is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe denture reline (D5751) provided on June 15, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says you have not tried a BiPAP device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage of a home ventilator have not been met. Our physician reviewer found the record 
shows you have diagnoses of interstitial lung disease and obstructive sleep apnea, and are on continuous 
positive airway pressure at night and oxygen.  A history of COPD is mentioned in an addendum, but there is no 
other evidence supporting that diagnosis.  There is no documentation of CO2 retention.  Certain BiPAP devices 
can provide the mode of support that has been ordered.  A home ventilator 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require anacute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement, however, the documentation doesn't support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power options for a power wheelchair for the 
enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the approved power options come with their own switches. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that there is a medical need to control the power options 
through a joystick. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power options for a power wheelchair for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee has been trained in an independent 
exercise program. The  specialized skill, knowledge and judgment of a qualified therapist is not required to 
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
21, 2020, to May 27, 2020. 
 
You asked the Plan to pay for home health services. You say that these services don't require authorization. The 
Plan denied your request. The Plan says a RAP for these services has not been submitted. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
 
 
shows a RAP has not been submitted. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from May 21, 2020, to May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemultiple power options and an intelligent seating module for a wheelchair.You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads,chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate controldevices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities is sufficient to control any power options through their own switches.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 accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approvemultiple power options and an intelligent seating module for a wheelchair.