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

We decided that the Plan does not have to pre-approve 9 additional home health visits for skilled nursing care.
You asked the Plan to pre-approve skilled nursing visits. You say that the requested services are medically necessary for you. The Plan denied your request. The Plan says the requested services are not a medical necessity.
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 skilled nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found that the documentation doesn't support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional home health visits for skilled nursing care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient knee replacement surgery services provided March 16, 2020 to March 17, 2020.
You asked the Plan to waive the copayment for the outpatient surgery services. You say that the plan is deciding to leave your responsible for more costs and they need to recheck the claim The Plan denied your request. The Plan says the claim has been re-processed and the correct cost share has been 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 $100
copayment for outpatient surgery, 20% coinsurance for prosthetic device, $10 copayment for x-rays and diagnostic procedures and tests, $20 copayment, 20% coinsurance for Medicare Part B covered drugs for Outpatient hospital services, Prosthetic devices and related supplies, Outpatient diagnostic tests and therapeutic services and supplies, Outpatient rehabilitation services, Medicare Part B prescription drugs. You have been asked to pay $518.11 ($100 + $320.26 + $40 + $10 + $47.85) for the outpatient surgery services. The outpatient surgery services fall within the Outpatient hospital services, Prosthetic devices and elated supplies, Outpatient diagnostic tests and therapeutic services and supplies, Outpatient rehabilitation services, Medicare Part B prescription drugs benefit categories. 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 outpatient knee replacement surgery services provided March 16, 2020 to March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe consultation to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. You say that this is an emergency.The Plan denied your request. The Plan says there are in-network providers that can render the services, and the services are not emergent.Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 care that cannot be provided by network providers.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 doesnot have to pre-approvethe consultation to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single
level; each additional vertebral segment (CPT code 22614), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the clinical records do not show that the enrollee has tried and failed conservative
therapies for at least six (6) weeks. The Plan states the records do not show that the pain has impacted the
enrollee's activities of daily living for at least 6 months and the imaging does not correlate with the symptoms
or other clinical findings of unstable spine.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found criteria for spinal fusion surgery not met. There is no documentation of a recent and adequate
trial of conservative measures to include physical therapy.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve arthrodesis, posterior or posterolateral technique, single level; each additional vertebral
segment (CPT code 22614), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says this exceeds the limit set in the subscriber agreement.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the enrollee did physical therapy, home exercises, and you feel that an MRI is required to further treatment. The Plan denied your request. The Plan says the MRI is not necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found the provided records did not show reported symptoms or objective signs suggestive of a red flag diagnosis or progressive radiculopathy or other condition to justify MRI at this time. Therefore, this request for such 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT Code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research his needed to show safety and efficacy. 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT Code(s): 22869 and 22870), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveextracorporeal shockwave therapy for the enrollee.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered experimental and investigational.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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of treatment is currently considered investigational as there are not enough high quality studies supporting its general use for treating the enrollee's specific 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 therapy have not been met.Therefore, we decided that the Plandoes not haveto pre-approveextracorporeal shockwave therapy for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.

You asked the Plan to pre-approve 10 additional PT visits. You say that the additional 10 physical therapy
visits are medically necessary. The Plan denied your request. The Plan says the additional 10 physical therapy
visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 10 additional PT visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as
specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The
enrollee has had extensive prior therapy for this condition and the records do not demonstrate that the unique
skills of a professional therapist are required to safely and effectively provide treatment, that the services can
be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The
recent Physical Medicine and Rehabilitation document did not reveal significant functional deficits that require
additional formal physical therapy. The enrollee has been instructed in and is compliant in a home exercise
program. The requested services are not part of a maintenance program, are the specialized skill, knowledge
and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional PT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) electric stimulation (97032) and therapeutic exercises (97110) provided February 3, 2021 to February 5, 2021 by a chiropractor.
You asked the Plan to pay for the chiropractic services. You say that you called three times and was given a benefit quote. You feel the services should be covered because you were never informed of the limits. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) electric stimulation (97032) and therapeutic exercises (97110) provided February 3, 2021 to February 5, 2021 by a chiropractor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on September 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON psychotherapy services. You say that the medical records support the necessity of the services rendered. The Plan denied your request. The Plan says this was provided OON without prior authorization or a referral from a network provider. The Plan does not cover services in this situation.

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 the psychotherapy services provided on September 8, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on September 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON psychotherapy services. You say that the medical records support the necessity of the services rendered. The Plan denied your request. The Plan says this was provided OON without prior authorization or a referral from a network provider. The Plan does not cover services in this situation.
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 the psychotherapy services provided on September 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an outpatient surgery provided by a participating provider on February 3, 2021.

You asked the Plan to waive the co-payment for an outpatient surgery. You say that you have to get these injections for the rest of your life. You say that you cannot afford this every month. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for outpatient surgery/in-network/outpatient hospital.

You have been asked to pay $195 which is less than your co-payment amount of $295 for an outpatient surgery. The injection that you received is considered an outpatient surgery; therefore, the correct co-payment has been
applied. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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 co-payment for an outpatient surgery provided by a participating provider on February 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on February 1, 2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that the services were not referred by a network provider, nor were they approved in advance. 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 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 domiciliary or rest home visit provided on February 1, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve face masks.
You asked the Plan to pre-approve face masks. You say that the items are necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve face masks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 1, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered by the Plan. The Plan also says that you were not enrolled in February 2021, which would have offered you additional dental benefits for these services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the breast biopsy (19083) and the
diagnostic mammography (77065) provided on December 28, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $350
copayment for outpatient hospital surgery. Additionally, you must pay a $50 copayment for x-rays.
You have been asked to pay $350 which includes a $300 copayment for the outpatient hospital surgery
provided; this amount is less than the applicable copayment for this service. Additionally, you have been asked
to pay a $50 copayment for the mammogram x-ray provided. 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 copayments
for the breast biopsy (19083) and the diagnostic mammography (77065) provided on December 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 24, 2021.

You asked the Plan to pay for the ambulance services. 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 January 24, 2021. 

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 January 24, 2021.