Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 determineif the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the current acute care hospital with acute hypoxic respiratory failure related to recent COVID-19. He was treated with mechanical ventilation, tracheostomy, PEG, steroids, remdesivir, and antibiotics. Recent notes show he is improving with tolerance of weaning trial to trach collar.The enrollee appears to be more stable and improving with current treatment, but requires additional short term acute care until oxygen weaning is completed which can be safely performed at the current facility. The enrollee does not require LTACH servicesthat are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time.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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy-duty power operated vehicle (K0801).
You asked the Plan to pre-approve the heavy-duty power operated vehicle. You say that you would like
reconsideration because the member has muscular dystrophy and requires a larger chair for stability. The Plan
denied your request. The Plan says a Heavy-Duty Power Operated Vehicle (POV) is covered for a beneficiary
weighing 285-450 pounds.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 heavy-duty power operated vehicle.
Our reviewer says that the documentation is not clear that the requested K0801 is the appropriate size for this
member as the member weighs 265lbs. and does not meet the patient weight capacity of 301-450lbs. Our
physician reviewer found this power operated vehicle is not medically reasonable and 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 heavy duty power operated vehicle have not been met. Therefore, we
decided that the Plan does not have to pre-approve the heavy-duty power operated vehicle (K0801).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided from September 10, 2020 to September 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe drug testing services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 thePlan does not have to pay forthe drug testing services provided from September 10, 2020 to September 12, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric services provided on July 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe psychiatric services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe psychiatric services provided on July 23, 2020 byan out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) care provided on December 27, 2019, to January 17, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the IRF care. You say that these services were medically necessary. The Plan denied your request. The Plan says the provider is a non-participating provider with the Plan and the member does not have out of network benefits.
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 inpatient rehabilitation facility (IRF) care provided on December 27, 2019, to January 17, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that this visit was not pre-scheduled and therefore authorization was not obtained. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 the medical services provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe foot surgeries.You asked the Plan to pre-approvethe foot surgeries. You say that you would like reconsideration because these procedures are medically necessary.The Plan denied your request. The Plan says the documentation does not support that this level of care is 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 foot surgeries. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no documentation of a severe hallux valgus angle. There is no clear discussion of the need for hardware removal, relative to failed or painful hardware, and no evidence to support the medical necessity of a repeat first metatarsophangeal arthrodesis. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted.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 foot surgeries have not been met.Therefore, we decided that the Plan does not have to pre-approvethe foot surgeries.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora needle electromyography (95938) provided June 18, 2020.You asked the Plan to pay forthe needle electromyography. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95938 is not supported in the medical record. Specifically, rules require that this CPT code be reported with a Nerve Conduction Study (95905). Based on this information, we decided that Medicare rules for coverage of the needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay fora needle electromyography (95938) provided June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on August 28, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service 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 this service.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Surgical Placement Of Implant Body: Endosteal
Implant Tooth #2 and 15 (D6010 x2).
You asked the Plan to pre-approve the dental services. You say that you are unable to eat properly due to not
having proper dentures. The Plan denied your request. The Plan says the service is not a covered benefit under
the plan.
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. This service is not listed in your 2020 EOC as a covered benefit;
therefore, it is not covered. As the year has changed since the appeal began, please check your 2021 EOC for
coverage rules regarding your supplemental dental benefits. Therefore, we decided that the Plan does not have
to pre-approve Surgical Placement Of Implant Body: Endosteal Implant Tooth #2 and 15 (D6010 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia for hernia repairs in lower abdomen (00830) provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe anesthesia services. You say that the records should support the necessity of the service in dispute.The Plandenied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 areaurgent 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 foranesthesia for hernia repairs in lower abdomen (00830) provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forstress testing. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 has network providers available who can provide the items/services at issue in this appeal. The Plandid 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 medical services provided on June 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the benign lesion destruction (17111) rendered by the out of network (OON) provider on July 22, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99203) and the benign lesion destruction (17111) rendered by the out of network (OON) provider on July 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided March 23, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation did not support the CPT code billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code A0429 is not supported in the medical record. Specifically, Medicare requires that CPT
code A0428 with modifier QL be used in cases where the patient is pronounced deceased after the ambulance
was called but before transport takes place. Based on this information, we decided that Medicare rules for
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to
pay for ambulance services (A0429) provided March 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe brief emotional/behavioral assessments and domiciliary or rest home visits provided from June 19, 2020, to September 9, 2020, by an OON provider.You asked the Plan to pay forthe brief emotional/behavioral assessments and domiciliary or rest home visits. You say that these services were medically necessary for the enrollee.The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not 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 forthe brief emotional/behavioral assessments and domiciliary or rest home visits provided from June 19, 2020, to September 9, 2020,by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on August 17, 2020.You asked the Plan to pay forthe services provided. You say that you were in severe pain.The Plan denied your request. The Plan says there are no additional benefits remaining for 2020.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. We looked at the file, and Medicare rules. The records show that the Plan paid the $1000 maximum allowed amount for your dental benefit. We found no exception which would require the Plan to further pay for the services provided. Therefore, we decided thatthe Plan does not have tofurtherpay forthe dental services provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit (99442) provided July 20, 2020.You asked the Plan to waive the copayment forthe office visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was 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 $45 copayment for Specialist Visits. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the Specialist Visits benefit category. This means that you have been askedto 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 foran office visit(99442) provided July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requestedpsychotherapy services.You asked the Plan to pre-approve the psychotherapy services.The Plan denied your request. The Plan says the psychotherapy services denied are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counseloris not eligible to participate in the Medicare program.We looked at the file and Medicare rules. The provider at issuein this caseis a Licensed Professional Counselor.Medicare says that aLicensed Professional Counseloris not eligible to participate in the Medicare program.Therefore, we decided that the Plan does not have to pre-approve the requested psychotherapy services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 24, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
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 August 24, 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 provided . on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 2, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not request this service. 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 June 2, 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 provided on June 2, 2020.