Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Single Photon Emission Computed Tomography (SPECT) imaging (78306).
You asked the Plan to pre-approve the SPECT scan. You say that the whole body SPECT scan is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SPECT scan. Our reviewer says that the requested scan is not medically necessary. Our physician reviewer found the enrollee underwent repair for a partial rotator cuff tear. The enrollee was ordered a whole body SPECT scan. Reviewed records do not include history or physical examination findings, differential diagnosis, or provider rationale to support the requested study. 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 SPECT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Single Photon Emission Computed Tomography (SPECT) imaging (78306).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 23, 2019.You asked the Plan to pay forthis claim. You say that these services were medically necessary.The Plandenied 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 providethe 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 to the enrollee on July 23, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 7, 2018 through December 19, 2018 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you should not be liable for the cost-share because you did not know there would be a cost-share.The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on December 7, 2018 and discharged on December 19, 2018. You were asked to pay a $300 copayment per day from December 7, 2018 through December 11, 2018, days1-5 of your inpatient stay. There were no copayment charges from December 12, 2018, day 6 of your inpatient hospital care until your day of discharge December 19, 2018. Per your contract there is a $300 copayment per day required for days 1-5. 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 forinpatient hospital care from December 7, 2018 through December 19, 2018 provided by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by out of network provider.You asked the Plan to pre-approve cataract surgery. You say that you would like to see out-of-network provider.The Plan denied your request. The Plan says there are in-networkproviders available 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvecataract surgery to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, adult sized disposable brief/diaper (T4522).
You asked the Plan to pre-approve incontinence supplies. You say that you really needs the pull ups which is not a luxury for you but medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, adult sized disposable brief/diaper (T4522).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on June 19, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the erollee on June 19, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvefacet joint injections.You asked the Plan to pre-approvefacet joint injections. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the records do not show that the enrollee has failed an adequate trial of physical therapy and the diagnosis code submitted does not support medical necessity.The Plan follows Medicare rules. Medicare rules say that facet joint injections, including a second confirmatory medial branch block, are only covered when the enrollee meets certain specific criteria.We asked our physician reviewerto 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 facet joint injections. Our reviewer says that the enrollee meets the Medicare criteria for the requested facet joint injections. Our physician reviewer found the enrollee has failed conservative therapy, the first set of diagnostic facet injections had greater than 80% pain relief, and therefore the requested second set of diagnostic blocks is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have been met.Therefore, we decided that the Plan has to pre-approvefacet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by out of network provider.You asked the Plan to pre-approve the office visit. You say that the service should be covered.The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean office visit to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960).
You asked the Plan to pay for the SEWHO. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines. There was also no itemized shipping/billing invoice indicating the specific supplies provided.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthosis (SEWHO) (L3960).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy techniques (97140) provided May 23, 2019 and May 30, 2019.You asked the Plan to pay for the manual therapy techniques. You say that you are requesting reconsideration of the Plan's denial as the services provided to the patient were medically necessary.The Plan denied your request. The Plan says the services provided are not a covered benefit under the member's policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the manual therapy techniques (97140) provided May 23, 2019 and May 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Myocardial Perfusion Study provided on April 26, 2019.You asked the Plan to waive the coinsurance forthe Myocardial Perfusion Study. You say that the coinsurance should be waived.The Plan denied your request. The Plan says the correct coinsurance was applied.The rules saya 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 20% coinsurance for Outpatient Diagnostic Tests. You have been asked to pay a 20% coinsurance for the Myocardial Perfusion Study. The Myocardial Perfusion Study falls within the Outpatient Diagnostic Tests 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 coinsurance fora Myocardial Perfusion Study provided on April 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure (43284). You asked the Plan to pre-approve the LINX procedure. You say that the FDA has approved this procedure as safe and effective and conservative treatment has not resolved your condition. The Plan denied your request. The Plan says this procedure has not been proven effective for treatment of heartburn.The Plan must follow Medicare rules. Medicare rules say that 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 the LINX procedure have not been met. Per Local Coverage Article: Billing and Coding: Non-Covered Services (A57642), the PINX procedure (43284) is non-covered as it has not been proven to be effective or medically necessary.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that it is felt that the enrollee should be covered for care in the SNF setting. The Plan denied your request. The Plan says there is no need for daily skilled care. Needs are mainly custodial.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The patient does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This patient does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee is with multiple falls. He has had weakness and difficulty ambulating and completing activities of daily living. His prior level of function was living alone in a 2 story home and independent with activities of daily living and ambulated with a walker or cane. His current level of function documented in October 2019 was minimal assist with bed mobility, minimal assist with transfers, ambulating 40-50 feet with a rolling walker with minimal assist, and upper and lower body dressing with minimal assist. Based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admissionand services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 13, 2019.You asked the Plan to pay forthese 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 atthe 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 forthe drug testing rendered on September 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided July 26 to July 30, 2019.You asked the Plan to pay forthe hospital services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan contracted hospital.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
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 hospital services. Our reviewer says that the post-stabilization inpatient services do not meet coverage criteria. Our physician reviewer found the records show that the enrollee was stable for transfer by ambulance to an in-network facility after the initial emergency room services. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.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 hospital services have not been met.Therefore, we decided that the Plan does not have to pay forpost-stabilization inpatient hospital care provided July 26 to July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered on August 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99190 is not supported.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on August 26, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency clinic services provided on September 18, 2019.
You asked the Plan to pay for the emergency clinic services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. This practice is a freestanding ER facility that is not affiliated with a hospital. Under Medicare rules, this type of provider is not eligible for Medicare reimbursement. Based on this information, we decided that Medicare rules for coverage of the emergency clinic services have not been met. Therefore, we decided that the Plan does not have to pay for emergency clinic services provided on September 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS non-emergency ambulance service to a physician's office.
You asked the Plan to pay for the ambulance service. You say that the enrollee slides off of the wheelchair when riding in a wheelchair and is unable to be picked up. The enrollee needs a Hoyer lift to get onto the wheelchair. The Plan denied your request. The Plan says ambulance transportation to a doctor's office is not a covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for BLS non-emergency ambulance service to a physician's office.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by an out of network provider.
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 out of network provider.