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

We decided that the Plan does not have to pay for an office visits provided on June 26, 2020 to September 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visits. You say that you did not know about needing a referral. 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 had network providers available who could have provided 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 an office visits provided on June 26, 2020 to September 28, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for total knee replacement. Post-operatively he was diagnosed with atrial fibrillation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on March 12, 2020.
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 code 99291 is 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4222).

You asked the Plan to pay for the infusion supplies. You say that you would like reconsideration because you
provide home infusion, and the infusion supplies were omitted from reimbursement. The Plan denied your
request. The Plan says the documentation submitted does not include a physician order for these supplies.

The Plan must follow Medicare rules. Medicare rules say that when an infusion pump is covered, the drug
necessitating the use of the pump and necessary supplies are also covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the infusion supplies have not been met. Specifically, Medicare criteria for the pump have not been
met; therefore, the billed supplies are not covered. Therefore, we decided that the Plan does not have to pay for
infusion supplies (A4222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120).

You asked the Plan to pay for the dental items. You say that the secretary at the dental office advised that the provider was in network. You also say that the claim was denied. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services are only covered when you use providers that are in the Plan's Dental network. The Plan also says that there are in network dentists that could have provided the services.

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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig and sales tax provided September 3, 2020. You asked the Plan to pay for these services. You say that you were not aware this was not covered. The Plan denied your request. The Plan says that this is not a covered benefit. Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is non covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to pay for the wig and sales tax provided September 3, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the private duty nursing services rendered on February 3, 2020.
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 code T1000 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The services at issue are billed with code T1000. This code has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the private duty nursing services rendered on February 3, 2020.
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. You say that you are not well enough to be at home and your health has declined. The Plan denied your request. The Plan says an IRF admission is not appropriate given the clinical scenario.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for metabolic encephalopathy and hypoglycemia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that you required follow up visits when you were
released from the hospital. You say that the claims should be paid because of a medical emergency. The Plan
denied your request. The Plan says that this provider is not a network with the Plan.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. There were no medical records submitted to determine if the services were
urgent or emergent. Therefore, we decided that the Plan has to pay for the office visit provided by an out-of-network
provider.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature and an attendant control for the enrollee.
You asked the Plan to pre-approve a power seat elevation feature and an attendant control. You say that this is medically necessary. The Plan denied your request. The Plan says that a seat elevator is not covered by Medicare and an attendant control cannot covered in addition to a beneficiary-operated joystick.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Medicare rules also say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. We looked at the file and Medicare rules. An attendant control cannot be covered in addition to the enrollee-operated device control system already being provided with the approved power wheelchair. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature and an attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature and an attendant control for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the lower extremity (73700) provided on September 10, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment of this service.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. You were enrolled under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the lower extremity (73700) provided on September 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 26, 2019.
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 October 26, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 26,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power Wheelchair (K0825). You asked the Plan to pre-approve the Power Wheelchair. You say that the power wheelchair is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. No medical records were provided to support the need for the Power Wheelchair. The plan made multiple requests for additional documentation and none was provided. Based on this information, we decided that Medicare rules for coverage of the Power Wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a Power Wheelchair (K0825).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the abdominal/pelvic CT Scan.
You asked the Plan to pre-approve the abdominal/pelvic CT Scan. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the member no longer has pain.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 abdominal/pelvic CT Scan. Our reviewer says that there was no report of current symptoms, plans for a procedure, or other indication for imaging to justify this request. Our physician reviewer found CT pelvis 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 abdominal/pelvic CT Scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the abdominal/pelvic CT Scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the recement of a crown (D2920 x 2), the panoramic x-ray (D0330), the complete series x-ray (D0330), the 2D oral/facial photographic images (D0350 x 4), the comprehensive oral evaluation (D0150), and the unspecified preventive service provided on October 22, 2020.
You asked the Plan to pay for the dental services. You say that after you received the services, you learned that the provider was actually in network. You say that you are not responsible for their error in seeing the provider in this case who was not in the Medicare Network on the date of service. The Plan denied your request. The Plan says recement of crowns, panoramic x-rays, photographic images, complete series x-ray, and unspecified preventive service are not listed as covered services. The Plan says that 1 comprehensive oral evaluation is covered every 3 years. The Plan also says that the frequency limit for this service has been exceeded.
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 recement of crowns, panoramic x-rays, photographic images, complete series x-ray, and unspecified preventive service are not among those covered under this benefit. Additionally, the frequency limit of 1 comprehensive oral evaluation every years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on January 5, 2018. Therefore, we decided that the Plan does not have to pay for the recement of a crown (D2920 x 2), the panoramic x-ray (D0330), the complete series x-ray (D0330), the 2D oral/facial photographic images (D0350 x 4), the comprehensive oral evaluation (D0150), and the unspecified preventive service provided on October 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from October 1, 2020, to October 18, 2020. You asked the Plan to waive the copayment for SNF care. You say that you would like this stay separated from the previous stay so that the first 20 days are covered. The Plan denied your request. The Plan says the copayment amount that the enrollee is being charged is correct. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 17 days, which are days 18 to 35 of the benefit period, resulting in a total copayment amount of $2,670. The enrollee has been asked to pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. The enrollee had not been discharged from skilled care in a SNF for 60 consecutive days at this point. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided from October 1, 2020, to October 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a peripheral nerve stimulator (64555). You asked the Plan to pre-approve the implantation of a peripheral nerve stimulator. You say that this is a medically necessary and Medicare-covered service. The Plan denied your request. The Plan says this is not supported for the enrollee's condition. The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must include a psychological evaluation. The file does not show that a psychological evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve the implantation of a peripheral nerve stimulator (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on September 2, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered.
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 problem focused limited oral evaluation and first intraoral periapical x-ray provided on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral vertebroplasty.
You asked the Plan to pre-approve sacral vertebroplasty. You say that the requested sacral vertebroplasty is medically necessary. The Plan denied your request. The Plan says the requested sacral vertebroplasty is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve sacral vertebroplasty. Our reviewer says that the requested sacral vertebroplasty is not medically necessary. Our physician reviewer found the enrollee is with severe intractable pelvic/sacral pain limiting mobility and function, diagnosed with bilateral sacral insufficiency fractures. Sacral vertebroplasty remains experimental. More research is needed to show safety and efficacy of cement in the sacrum. The requested sacral vertebroplasty is 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 sacral vertebroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral vertebroplasty.