Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services. You asked the Plan to pre-approve continued home health services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee no longer needs skilled care. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued home health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not show that continued skilled nursing services are required to effectively provide treatment, care, or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition or prevent deterioration. The patient's medical conditions are chronic and stable. There is no indication that leaving the home is a significant and taxing effort. The patient has had extensive education in disease and medication management. The skills of a professional nurse for additional home health care services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 30, 2019 by a non-network provider.You asked the Planto pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 referring provider 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 laboratory services provided on September 30, 2019 by a non-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (A9270) provided February 8, 2020.
You asked the Plan to pay for the emergency room services. You say that the claim should be paid. The Plan denied your request. The Plan says code A9270 is non-covered under Medicare.
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 A9270 is Non-covered items. We find that CPT code A9270 is not supported in the medical record. Specifically, this code is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (A9270) provided February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mindfulness Based Stress Reduction program provided on January 1, 2019.
You asked the Plan to pay for the Mindfulness Based Stress Reduction program. You say that this should be reimbursed. The Plan denied your request. The Plan says that this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a gym 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 Mindfulness Based Stress Reduction program provided on January 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (HCPCS A4550) provided to the enrollee on December 17, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the denied code is included in the payment of the other services performed on the same date.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code A4550 is not supported in the medical record. Specifically, the denied codes a MPFSDB Status Indicator of B, which means that payment for this code is always bundled into other services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for injection services (HCPCS A4550) provided to the enrollee on December 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary, rest home visits provided from December 24,
2019 to February 4, 2020.
You asked the Plan to pay for the domiciliary, rest home visits. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for domiciliary, rest home visits provided from December 24, 2019
to February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99071) provided on December 20, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service. The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99071 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99071) provided on December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aralast NP.You asked the Plan to pre-approve Aralast NP. You say that the medication is necessary.The Plan denied your request. The Plan says the dosage requested exceeds the recommended dose in the medication prescribing information. Therefore, the coverage criteria has not been met.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 Aralast NP. Our reviewer says that the dosage is not medically necessary. Our physician reviewer found based on the medical records provided the 7040 mg per week dose of Aralast NP is not medically reasonable and necessary or safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aralast NP have not been met.Therefore, we decided that the Plan does not have to pre-approve Aralast NP.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CX bladder testing received on December 16, 2019. You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this testing is not a covered benefit. 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 testing. Our reviewer says that the testing at issue in this case is not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage your condition. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the CX bladder testing received on December 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on October 14, 2019 by an OON provider.You asked the Plan to pay for the wound care services. You say that the facility failed to obtain the necessary authorization for this enrollee because the enrollee is entitled to receive surgical dressings. You also say that the wound care services were medically necessary.The Plan denied your request. The Plan says the wound care services were not authorized prior to 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 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 wound care services provided on October 14, 2019 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electronic analysis of a programmable pump provided on February 11, 2020.
You asked the Plan to waive the copayment for the pump analysis. You say that this was a follow-up visit and do not feel like you should be charged for an adjustment of the pump. 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 $150 copayment per visit for outpatient hospital services. You have been asked to pay a $150 copayment for the pump analysis. The pump analysis falls within the "Outpatient hospital services" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a previous procedure.
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 electronic analysis of a programmable pump provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute care hospital on 5/17/20 with shortness of breath. She was diagnosed with respiratory failure, and was intubated. Her past medical history is notable for mitral valve replacement, congestive heart failure, respiratory failure, hypertension, GERD, cystic kidney disease, and morbid obesity. The enrollee's overall respiratory prognosis was deemed to be poor. A tracheostomy and PEG tube were subsequently placed. The enrollee transitioned to DNR status, with hospice services. The enrollee is on continuous BiPAP to the tracheostomy. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. It is noted on 6/11/20 that the plan is for inpatient hospice. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy provided from October 29, 2019 to December 10, 2019. You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says the provider is not contracted with the Plan and no authorization was requested.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 inthis 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 infrared therapy provided from October 29, 2019 to December 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the home health services provided on January 3, 2020 and January 6, 2020.You asked the Plan to waive the deductible for the home health services. You say that you do not agree with having to pay because no therapy was done. 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. Your contract with the Plan says that there is a $750 deductible that applies towards home health services. The home health services you asked the Plan to waive the deductible for falls within the "Home health services" benefit category The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards home health services. The medical record shows that home health services were received.This cost sharing is a contractual obligation that had not been met at the time the home health services were received on January 3, 2020 to January 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the home health services provided on January 3, 2020 and January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive pharmacogenetics testing provided to the enrollee on August 29, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says services determined not effective are not covered.
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 testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive pharmacogenetics testing provided to the enrollee on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on January 20, 2020.
You asked the Plan to waive the copayment for the EKG. You say that the test was done in conjunction with an office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the copayment 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 $10 per day for Medicare-covered tests. You will only pay one copayment per day even if multiple tests are performed. You have been asked to pay a $10 copayment for the EKG. The EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 EKG provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for EPAT services provided on February 21, 2020.
You asked the Plan to pay for the EPAT services. You say that you would like reimbursement for the podiatry services rendered. The Plan denied your request. The Plan says this is not a Medicare covered benefit and there is no life at imminent risk or risk of losing an organ.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the EPAT services have not been met. Specifically, this service is not a Medicare covered benefit and the record indicates that the provider informed you that this service would not be covered. Therefore, we decided that the Plan does not have to pay for EPAT services provided on February 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February 8, 2020. You asked the Plan to waive the copayment for the ambulance ride. You say that your insurance should cover this. You say you needed the ambulance and therefore you should not have to pay the copayment. 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 $325 copayment for Medicare-covered ambulance services per trip. You have been asked to pay a $325 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 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic mammogram (77065) provided January 10, 2020.
You asked the Plan to pay for the mammogram. You say that there were multiple exams performed. The Plan denied your request. The Plan says the records do not support multiple exams.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 77065 are not supported in the medical record. The medical record only supports 1 unit of CPT code 77065. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a diagnostic mammogram (77065) provided January 10, 2020.