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

We decided that the Plan does not have to pay for chiropractic services provided from January 8, 2020 to April 20, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you received from an out of network provider will not be covered. You received out-of-network services without prior-authorization and services were available in network.
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 chiropractic services provided from January 8, 2020 to April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vancomycin and Cefazolin for use with an external
infusion pump for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is needed related to a hip infection. The Plan
denied your request. The Plan says these drugs are not indicated for use with an external infusion pump.
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 the drugs. Our reviewer says that the
requested drugs are not medically reasonable or necessary. Our physician reviewer found the enrollee was
diagnosed with an infection of an internal joint prosthesis. A PICC line was placed and she was ordered
recurrent antibiotics. Review of the guidelines does not support the use of an infusion pump for the enrollee's
medications. Medical necessity is not determined.
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 drugs have not been met. Therefore, we decided that the Plan does not have
to pre-approve Vancomycin and Cefazolin for use with an external infusion pump for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 16, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires the enrollee to obtain covered services from Plan providers except for emergency care and out-of-area urgent 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 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 subsequent nursing facility care provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and surgical services provided on December 12, 2019 through January 10, 2020.
You asked the Plan to pay for the office visit and surgical services. You say that you would like reconsideration because you were not aware that this provider had opted-out of Medicare. The Plan denied your request. The Plan says Medicare does not provide coverage for providers who are opted-out with 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 a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for an office visit and surgical services provided on December 12, 2019 through January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided, on February 25, 2020 and March 2, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from a network provider in most cases.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 that you provided, on February 25, 2020 and March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete denture (D5120) provided on May 1, 2019.
You asked the Plan to pay for the complete denture. You say that you would like reconsideration because the member knows this provider. The Plan denied your request. The Plan says these services were not authorized or rendered in network by a certified lab.
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. Except for in specific circumstances, the Plan required the use of network providers. This provider is not in-network with the Plan. The record also indicates that this service was not authorized and that there are other providers available to render this service within the Plan's network. Therefore, we decided that the Plan does not have to pay for a complete denture (D5120) provided on May 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthoses provided on August 2, 2019.
You asked the Plan to pay for the wrist hand orthoses (L3908). You say that the orthoses were medically
necessary. The Plan denied your request. The Plan says the medical records do not support the claim.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at review the file, and Medicare rules. The medical record does not mention or support medical
necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the wrist
hand orthoses (L3908) have not been met. Therefore, we decided that the Plan does not have to pay for the
wrist hand orthoses provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan and a cardiology stress test provided on November
22, 2019.
You asked the Plan to pay for the CT scan and cardiology stress test. You say that the services were medically
necessary. The Plan denied your request. The Plan says the enrollee must receive care from in-network
providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service
area or if the care cannot be provided with an in-network provider, which requires prior authorization from the
plan.
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 a CT scan and a cardiology stress test provided on November 22,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on October 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider for the date of services in question. Without these records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hemoglobin testing provided on August 5, 2019.You asked the Plan to pay forthe hemoglobin testing. You say that this provider is credentialed and should be paid for the rendered services.The Plan denied your request. The Plan says it was found that the provider does have a valid license in Missouri and payment was made for the drug testing. However, there is no documentation of the results of the hemoglobin test to support payment of this code.The Plan must follow Medicare rules. Medicare rules say that suppliers must submit sufficient documentation to support that Medicare criteria are met. In this case, although there is notation of a hemoglobin test being necessary, the record do not include the results to support that this was performed.Therefore, we decided that the Plan does not have to pay forthe hemoglobin testing provided on August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam provided on February 4, 2020.You asked the Plan to waive the copayment forthe eye exam. The Plan denied your request. The Plan says that the cost share 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 each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe eye exam provided on February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies; however, your functional level does not require or indicate that this therapy can be tolerated in an inpatient rehabilitation facility with an intensive level program.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling on three surfaces (D2393) provided on January 29, 2020. You asked the Plan to pay for a filling on three surfaces. You say that this should be paid instead of one of the fillings on two surfaces. The Plan denied your request. The Plan says these fillings were paid and denied based on the order in which they were billed. 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. The Plan covers up to two fillings per year. We looked at the file and Medicare rules. The record shows that you received three fillings on this date of services. The two listed first on the claim were paid for by the Plan. Based on this information, we decided that the Plan's rules for coverage of a filling on three surfaces have not been met. Therefore, we decided that the Plan does not have to pay for a filling on three surfaces (D2393) provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam provided on February 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe eye exam. You say that you have been treated by this provider for years.The Plan denied your request. The Plan says that  before the member receives services from an ophthalmologist for diagnosis and/or treatment of a medical condition of the eye, the member must first obtain a referral from their primary care physician.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 thisappeal. 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 forthe eye exam provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift mechanism.You asked the Plan to pre-approveseat lift mechanism. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this equipment is not medically necessary.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 seat lift mechanism. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested seat lift mechanisms. Our physician reviewer found the documentation does not reveal objective imaging evidence of severe arthritis of the hip or knee and the enrollee does not have a severe neuromuscular disease. The seatlift mechanism was prescribed to assist the enrollee in arising from sitting but is not prescribed to stop or slow deterioration in the enrollee's medical conditions. There is no objective evaluation of the enrollee indicating that the enrollee is completely incapable of standing up from a regular armchair or any chair in their home. The office note indicates the enrollee is ambulatory.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift mechanism.
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 paramedics were called on the date of
service because you were experiencing bad chest pains. You say that the responders performed an EKG on you
and found nothing wrong. You stated that you decided not to be transported. 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 January 12, 2020. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January
30, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you were told to mail in any
bill received from outside providers. 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 $5
copayment for in-network Medicare-covered lab services.
You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the laboratory work provided on January 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from August 10, 2019 to August 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that that this 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. 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 and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from August 10, 2019 to August 12, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services starting June 17, 2020.You asked the Plan to pre-approveinpatient psychiatric services. You say that you would like the plan to reconsider their denialThe Plandenied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the documentation does not support that the requested inpatient psychiatric services are medically reasonable or necessary. Our physician reviewer found you were involuntarily admitted to the acute inpatient psychiatric hospitalization on May 25, 2020 with Paranoid Schizophrenia. While you had auditory hallucinations, you did not have visual hallucinations. You were compliant with treatment. The documentation did not support that you required inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others. Therefore, you do not meet criteria for the requested additional inpatient mental health 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 inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services starting June 17, 2020.