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

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF is not medically necessary as the enrollee does not meet Medicare criteria.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February 20, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that should not be responsible for the ambulance ride because it was medically necessary. 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 $250 copayment for one-way ground travel trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on November 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 99497 and 73130-LT are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99497 is advance care planning by the physician or other qualified health care professional, first 30 minutes. The definition of code 73130 is radiologic examination, hand; minimum of 3 views. We find that CPT codes 99497 and 73130-LT are not supported in the medical record. Specifically, there is no documentation of advance care planning for a change in the beneficiary's health status and/or wishes regarding end of life care to support code 99497. There is no documentation of a hand x-ray on the left side to support code 73130-LT. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 27, 2017
through October 2, 2017.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from September 27, 2017 through October 2, 2017.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 28, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit (99214) and urinalysis (81001). You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says the rendering provider is not a network provider with the Plan and the services were not referred by a network provider.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 medical services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe new patient eye exam (92004) renderedby the out of network (OON) provider on January 21, 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 provided 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 new patient eye exam (92004) renderedby the out of network (OON) provider on January 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services. You asked the Plan to pre-approve the SNF services. You say that SNF 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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. Services can be provided in an outpatient setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral
periapical x-ray provided on November 13, 2017.
You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You
say that you were not aware that you had dental insurance prior to 2020. You also say that your dentist did not
mention it and you did not know. The Plan denied your request. The Plan says these services are not covered
benefits.
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 contract clearly states that only 1 dental bitewing x-ray is covered
every year. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and
additional intraoral periapical x-ray provided on November 13, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture, three replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, and implant /abutment supported removable mandibular denture for edentulous arch provided on January 7, 2020 by an OON provider.
You asked the Plan to pay for the complete maxillary denture, replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, and implant /abutment supported removable mandibular denture. You say that prosthodontic services are a covered benefit under your plan. You also say that your plan did not have any prosthodontists located within a 100 mile radius of your home. The Plan denied your request. The Plan says the services were provided by an OON or non-contracted provider. The Plan also says that your plan does not allow for OON benefits.
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 covered when they are received OON. The Plan says that you were advised that your plan does not allow for OON benefits. The Plan also says that in order to see an OON provider, a special agreement must be completed with the provider, and the information to do so was not provided. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture, three replacements of semi-precision or precision attachment of implant/abutment supported prosthesis, and implant /abutment supported removable mandibular denture for edentulous arch provided on January 7, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) and adjunctive
procedure (D9999) provided on January 28, 2020.
You asked the Plan to pay for the bone replacement graft and adjunctive procedure. You say that you did not
receive the information from the Plan until after your appointment, advising that this provider is no longer innetwork
with your plan. The Plan denied your request. The Plan says these services are not covered benefits.
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. Therefore, we decided that the Plan does not have to pay for the bone
replacement graft (D7953) and adjunctive procedure (D9999) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forvision services provided on March 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forvision 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 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 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 forvision services provided on March 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-One.You asked the Planto pre-approvethe Gel-One. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says the documentation does not support the medical necessity for a step-therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Gel-One. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the provided records do not show any evidence of the patient having tried and failed either Monovisc or Orthovisc for the knees. Monovisc and Orthovisc would be essentially equal in their effectiveness and safety compared to the requested Gel-One, according to available evidence. There was no indication that the patient had any unique medical history or circumstances where Gel-One might be more appropriate than the preferred medications.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services beginning June 26, 2020.
You asked the Plan to pre-approve SNF services. You say that the enrollee couldn't take care of herself due to being extremely weak. The Plan denied your request. The Plan says that supervision could be provided at a long term care facility with isolation measures.
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 SNF services.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services. have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services beginning June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5267) purchased January 24, 2020.
You asked the Plan to pay for the hearing aids. You say that you had difficulty with the old hearing aids since
the beginning. Your new audiologist discussed changing hearing aids. You tried the new hearing aid and
noticed an immediate difference. The Plan denied your request. The Plan says this request exceeds the benefit
frequency limitation.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only once every 4 years. The records show that you received hearing aids on January 17, 2017.
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5267) purchased January 24,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for medical nutrition therapy. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 medical nutrition therapy provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 23, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 20, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for these services. You say that you were out of state and were at risk of infection
from a foot injury. 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 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 provided on March 20,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye exam provided on February 5, 2020.You asked the Plan to waive the copayment foran eye exam. You say that this exam was a screening and you should not owe a copayment.ThePlan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for exams to diagnose and treat diseases of the eye and a $0 copayment for retinopathy screenings for members with diabetes and for prescription eyewear post-cataract surgery.The medical records show that you received a diagnostic eye exam on February 5, 2020. Therefore, you are responsible to pay the $40 copayment.  You have been asked to pay a $40 copayment for an eye exam. An eye exam falls within the vision care 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 foran eye exam provided on February 5, 2020.