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

We decided that the Plan does not have to pay for the services rendered to you outside of the United States on June 12, 2018 to July 12, 2018.
You asked the Plan to pay for these services. You say that you needed the services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare generally does not cover items and services furnished outside of the United States. The Plan contract says that you have worldwide coverage for emergency care. We looked at the file and Medicare rules. The file shows that you were hospitalized in Costa Rica from June 12, 2018 to June 16, 2018 for lower leg pain. The services were not an emergency and are not covered. Therefore, we decided that the Plan does not have to pay for the services rendered to you outside of the United States on June 12, 2018 to July 12, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services (90834) provided on August 20, 2019.
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing 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 $10 copayment for Specialist Office Visits. You have been asked to pay a $10 copayment for the outpatient mental health services. The outpatient mental health services fall within the Specialist Office Visits 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 outpatient mental health services (90834) provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair expandable control system and harness.
You asked the Plan to pre-approve a power wheelchair expandable control system and harness. You say that the enrollee cannot operate the switch for the seat function. The Plan denied your request. The Plan says you do not have three or more power seating features on your approved power wheelchair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair expandable control system and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair expandable control system and harness.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99308) provided on August 8, 2019 by out of network provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided by out-of-network physicians. They were not emergent and there were network providers available. There was no preauthorization on file.
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 physician services (99308) provided on August 8, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on September 20, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says a referral (approval inadvance) from the enrollee's Primary Care Physician is required before the enrollee sees a Plan specialist or certain otherproviders. There was no prior authorizationon file forthese 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon September 20, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the ExoDx Prostate (Intelliscore) and EPI test provided to the enrollee on October 9, 2019.You asked the Plan to pre-approve the test. You say that this is medically necessary.The Plan denied your request. The Plan says that this is listed by the Medicare guidelines as not medically necessary, and therefore, not covered.The Plan must follow Medicare rules. Medicare rules say that testing is covered if it is 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 test. Our reviewer says that the services at issue in this case were medically reasonable and necessary. Our physician reviewer found following the LCD finalization, more than 60 million Medicare beneficiaries will now be covered for the EPI test effective December 1, 2019. The EPI test is a non-invasive, non-DRE requiring, urine-based, liquid biopsy test intended for men 50 years of age and older who have an elevated Prostate Specific Antigen (PSA) level between 2 -10 ng/mL and who are being considered for a prostate biopsy. This liquid biopsy test recently received FDA Breakthrough Designation and is included in the NCCN guidelines for early detection in men for both initial and repeat biopsy. The review has determined that the enrollee meets the criteria for this test.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 test have been met.Therefore, we decided that the Plan has to pre-approvethe ExoDx Prostate (Intelliscore) and EPI test provided to the enrollee on October 9, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that lymphedema regardless of etiology or location is a chronic and progressive condition that must be recognized, addressed and treated promptly to prevent further complications. The Plan denied your request. The Plan says you have not had a 4 week trial that shows failure of either E0650 or E0651 with daily manual lymph drainage and measurements for both legs before and after treatment with the device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee from August 9, 2019 to August 10, 2019.You asked the Plan to pay forthis claim. You say that this claimshould be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forphysician services provided to the enrollee from August 9, 2019 to August 10, 2019.
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 services are necessary. The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.
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 review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99328) provided on October 16, 2019.
You asked the Plan to pay for this service. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 11, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99328) provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device.You asked the Plan to pre-approve the requested item. You say that the device is the only thing that is giving you relief from pain.The Plan denied your request. The Plan says you have not enrolled in a clinical study.The Plan must follow Medicare rules. Medicare rules say that a TENS for chronic low back pain is only covered in an approved clinical study. We looked at the file and Medicare rules. The records provided do not show that you are enrolled in a Medicare-approved clinical study. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forunlisted neurological or neuromuscular diagnostic procedure (95999).You asked the Plan to pay forthis claim. You say that this service was medically necessary and should be paid.The Plan denied your request. The Plan says under Medicare rules, the request for separate payment of theseservices is not a covered benefit. The Plan states the records show the enrollee underwent neck surgery requiring neurophysiology monitoring. The claim request does not meet the conditions for approval because the "Train of Four"is considered a bundled procedure and payment for it is included in payment for the previously approved neuromonitoring. This serviceis considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled payment.This code cannot be billed separately. 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, code 95999 is bundled within another code an cannot be paid as billed. Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay forunlisted neurological or neuromuscular diagnostic procedure (95999).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided on August 1, 2019.
You asked the Plan to pay for home infusion therapy. You say that this code should be paid. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hepatitis B vaccine received on October 8, 2019.You asked the Plan to pay for the vaccine. You say that this is not medically necessary.The Plan denied your request. The Plan says this is denied, and should be submitted to the RX carrier.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay for the hepatitis B vaccine received on October 8, 2019
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled services provided to the enrollee from June 24, 2019 to June 28, 2019.
You asked the Plan to pay for skilled services provided to the enrollee from June 24, 2019 to June 28, 2019. You say that this claim should be paid. The Plan denied your request. The Plan says that an incorrect Core Based Statistical Area (CBSA) number for value code 61 was used. Chapter 10 of the Medicare Claims Processing Manual, which is for Home Health Agency Billing, speaks to the requirement of a CBSA when value code 61 is billed.
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 8 pages in the file submitted. Other than the denial letter there were no medical records or specific explanation of the case itself. The Plan submitted an incomplete case file from which we are unable to substantiate the Plans denial. Therefore, we decided that the Plan has to pay for skilled services provided to the enrollee from June 24, 2019 to June 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 15, 2019 through April 23, 2019.
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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. He had stable vital signs and no complaints at the time of admission. Inpatient services were not supported by the documentation. 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 15, 2019 through April 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
You asked the Plan to pre-approve the requested bed. You say that a full electric hospital bed is required for the enrollee's safety and protection. The Plan denied your request. The Plan says Medicare nor the plan covers this type of bed.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the physician.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the physician.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 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 Synvisc-One. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).