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

We decided that the Plan does not have to pay for the chiropractic evaluations you had on December 18, 2019,
and December 27, 2019.
You asked the Plan to pay for the evaluations. You say that this should be covered. The Plan denied your
request. The Plan says an initial evaluation is only covered once per year.
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 $15
copayment for one chiropractic initial evaluation per calendar year.
Review of the file shows that you were provided chiropractic evaluations on December 18, 2019, and
December 27, 2019. The records also show that the plan covered an initial chiropractic evaluation on
December 10, 2019. This service is only covered once per calendar year. The two evaluations in question
exceed the benefit limit, and therefore, are not covered. This means that you have been asked to pay the correct
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the
chiropractic evaluations you had on December 18, 2019, and December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on November 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services were not referring by an in-network provider. 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 assisted living services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive ophthalmological services to be
provided by an out of network (OON) provider.
You asked the Plan to pre-approve vision care services. You say that you would prefer to receive these services
out-of-network. The Plan denied your request. The Plan says there are in-network providers qualified and
available for these 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 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
comprehensive ophthalmological services to be provided by an out of network (OON) provider.
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 was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF care. You say that the enrollee needs more services
at the SNF. The Plan denied your request. The Plan says the enrollee's mobility is at contact guard assist. The
Plan says that the enrollee's activities of daily living are at a contact guard assist level, or better. The Plan says
that the enrollee is medically stable with no current skilled nursing needs. The Plan says that the enrollee is
able to safely transfer to a lower level of care at 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 pre-approve the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no skilled
nursing needs. The enrollee is not receiving IV medications or fluids. There are no unaddressed medical
conditions or conditions that require complex monitoring or medication adjustment. The enrollee does require
physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive
equipment. However, these skilled therapy services are not needed on a daily basis. The enrollee's care can be
continued at an alternate 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on December 20,
2019.
You asked the Plan to waive the copayment for the facility fee. You say that you should not have to pay a
copayment from the hospital. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
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 $200
copayment for each Medicare-covered non-surgical outpatient hospital visit. For this date of service, you have
been asked to pay the allowed amount of the claim because this amount is less than the $200 copayment for the
non-surgical outpatient hospital visit.
You have been asked to pay a $97.39 copayment for the facility fee. The facility fee falls within the
"Outpatient hospital 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 copayment for the facility
fee provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical face masks.
You asked the Plan to pre-approve surgical masks. You say that you need face masks to protect against Covid-19. The Plan denied your request. The Plan says surgical masks are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that surgical masks do not fit the definition of durable medical equipment. While surgical masks may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve surgical face masks (A4928).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you fell and could not get back up. You say that you have fallen before and had to call for assistance but you were not charged. You stated that on previous occasions you were told that you did not have to pay for the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 16, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Image-Guided Lumbar Decompression (PILD) (0257T).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of this procedure.
The Plan follows Medicare rules. Medicare rules say that Percutaneous Image Guided Lumbar Decompression (PILD) is covered by Medicare when provided in a clinical study for beneficiaries with LSS who are enrolled in an approved clinical study that meets criteria. 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 this service. Our reviewer says that you do not meet criteria for coverage of Percutaneous Image-Guided Lumbar Decompression. Our physician reviewer found that you have low back pain with symptoms consistent with neurogenic claudication. Your functional limitations are noted in walking tolerance. You have been diagnosed with lumbar spinal stenosis. However, you are not enrolled in an approved clinical trial for the requested procedure based on the provider documentation. Therefore, Medicare criteria have not been 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Image-Guided Lumbar Decompression (PILD) (0257T).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided October 13, 2019 to October 18, 2019.You asked the Plan to pay forthe acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary.The Plandenied your request. The Plan says that the acute inpatient hospital care provided was 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 the 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 that the enrollee presented to the Emergency Department (ED) on October 13, 2019 with increased low back pain with an inability to walk more than 2-3 steps without increased pain. She was under the care of a pain management specialist and was treated with Methadone for pain control. Evaluation revealed increased pain with movements;she was additionally treated with IV fluids andPotassium Chloride (KCL), IV insulin, and IV Morphine Sulfate (MSO4) for pain control. She was admitted to telemetry and evaluated by Neurology. She underwent magnetic resonance imaging (MRI) of the brain which demonstrated microvascular changes and an MRI of the lumbar spine which revealed spinal stenosis. She also had an electroencephalogram (EEG). The enrolleewas evaluated by Physical Therapy. Shewas then evaluated by Cardiology for atypical chest pain. Her electrolytes normalized and she was discharged on October 18, 2019 when considered medically stable. The enrollee was to be recommended to Neurosurgery as an outpatient. The review indicates that the record showed that at the time of the inpatient admission,the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 the acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided October 13, 2019 to October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZilretta.You asked the Plan to pre-approveZilretta. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Zilretta. Our reviewer says that Zilretta is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that Zilretta injections are experimental for the treatment of knee degenerative joint disease (DJD). More research is needed to show safety and efficacy. Recent literature shows these injections are not effective for knee DJD management.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met.Therefore, we decided that the Plan does not have to pre-approveZilretta.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 20, 2019.
You asked the Plan to pay for the genetic testing (0037U). You say that the  testing provided was medically necessary. The Plan denied your request. The Plan says the testing provided was 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 pay for the  genetic testing (0037U). Our reviewer says that the  testing provided was not medically necessary. Our physician reviewer found treatment options for recurrent and metastatic cervical cancer are limited. Recently, PD-L1 testing is recommended as pembrolizumab has been shown to be an effective second line treatment in patients who express at least 1% staining. Molecular profiling is the subject of ongoing clinical trials and to date has not been shown to be superior to standard therapies and PD-L1 testing (which was done in this enrollee). The service was not reasonable or 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 the genetic testing (0037U) have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a nurse practitioner on January 28, 2020.You asked the Plan to waive the copayment for a specialist office visit. You say that you were not seen by anyone. 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 $30 copayment for physician/practitioner services/in-network/specialist's office. You have been asked to pay a $30 copayment for a specialist office visit. Since a prescription refill was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist's office 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 a specialist office visit provided by a nurse practitioner on January 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea repeat sleep study (95811).You asked the Plan to pre-approvea repeat sleep study. You say that thisshould be covered.The Plan denied your request. The Plan says a sleep test is not necessary for you to receive replacement equipment.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 repeat sleep study. Our reviewer says that at this time a repeat sleep study is not medically necessary. Our physician reviewer found you should be provided with a replacement mask and tubing, and then reassessed with symptoms and device download. If, after replacement, the treatment is ineffective, then a repeat split-night study with titration may be 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 repeat sleep study have not been met.Therefore, we decided that the Plan does not have to pre-approvea repeat sleep study (95811).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you did not know that these services were denied. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 an outpatient surgery provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99285 provided on November 14, 2019.
You asked the Plan to pay for CPT code 99285. You say that the medical records support the billing of CPT
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of CPT
code 99285.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect
the services provided.
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the
evaluation and management of a patient which requires three components (taking into account the urgency of
the clinical condition or the patient's mental status):
1. a comprehensive history;
2. a comprehensive examination; and
3. medical decision making of high complexity.
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate
significant threat to life or physiologic function.
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 CPT code 99285 Our reviewer says that the
medical records do not support the billing of CPT code 99285. Our reviewer found the enrollee presented with
left toe pain and drainage after surgery 4 days earlier. Vital signs were stable and there was no active wound
drainage. An x ray showed no foreign body. CBC and CMP were performed and were unremarkable. There
was no rationale included for ordering these tests and details in the history or plan which suggested that this
data was used in medical decision making. The medical decision making was of moderate complexity, no high
complexity. The medical records do not support the billing of CPT code 99285.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT code 99285 have not been met. Therefore, we decided that the Plan does
not have to pay for CPT code 99285 provided on November 14, 2019.