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

We decided that the Plan does not have to pre-approve two additional chiropractic visits.

You asked the Plan to pre-approve two additional chiropractic visits. You say that the enrollee needs additional
chiropractic treatment. The Plan denied your request. The Plan says an additional two chiropractic visits is
unreasonable and 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 two additional chiropractic visits. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has been undergoing treatment for nearly one year, for ache and pain
complaints, with no evidence of significant imaging findings, significantly decreased quantifiable measures of
range of motion and strength, orthopedic or neurological findings or any evidence of any significant findings
that reveals an enrollee who requires long-term, ongoing chiropractic treatment. There has been no reasonable
expectation of recovery or improvement of function. There is no reason why this enrollee cannot perform
independent, self-directed home exercises for any remaining aches and pains. The chiropractic treatments are
medically unnecessary, have exceeded a reasonable prognosis, are not supported by the submitted
documentation and are not supported by Medicare guidelines. Thus, chiropractic treatment is not supported or
allowed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of two additional chiropractic visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve two additional chiropractic visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl 100mcg/H for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl 100mcg/H for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you will get better with aggressive therapy. The Plan denied your request. The Plan says you are unable to tolerate or need an intensive therapy program.

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 physician reviewer found that you have a past medical history of spinal stenosis, diabetic neuropathy, and COVID-19. You are living at home and having trouble with ambulation and pain. Your medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says in most cases, care you receive from a non-network provider will not be covered.
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 physician's services. We found no exception that would require the Plan to pay for the physician's services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D7210, D0140, D0330, D4266) provided August 20, 2020.

You asked the Plan to pay for the dental services. You say that the injuries were a result of a medical emergency and the dental services should be covered. The Plan denied your request. The Plan says these services are not covered under your plan.

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 dental services (D7210, D0140, D0330, D4266) provided August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 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. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine microbial DNA analyses provided on June 30, 2020 billed with 17 units of code 87798.
You asked the Plan to pay for the 17 units of 87798. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says it was decided to make payment for this testing for two of the microorganisms tested as this is the limit imposed by the LCD.
The Plan must follow Medicare rules. Medicare rules say that no more than two individual microorganisms may be concurrently billed for CPT 87481 and 87798. The file shows that 17 microorganisms were billed for code 87798. This is in excess of what is allowed by the LCD. Therefore, we decided that the Plan does not have to pay for urine microbial DNA analyses provided on June 30, 2020 billed with 17 units of code 87798.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance care (A0998) provided September 11, 2020.
You asked the Plan to pay for the ambulance care. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says Medicare only covers ambulance services when the patient is transported.
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 September 11, 2020. 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 ambulance care (A0998) provided September 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set and infection control supplies billed with codes S1015 and S8301 for anesthesia services provided on March 9, 2020.
You asked the Plan to pay for these billed items. You say that since you provide anesthesia in the office setting, you are allowed to bill for each individual supply that you bring to the office. The Plan denied your request. The Plan says the billed S-codes are not valid for Medicare billing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Codes S1015 and S8301 have a status indicator of "I" in the Physician Fee Schedule, meaning that they are invalid for Medicare billing. Based on this information, we decided that Medicare rules for coverage of these billed items have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set and infection control supplies billed with codes S1015 and S8301 for anesthesia services provided on March 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan to be
provided by an OON provider.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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 care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 an MRI scan. Our reviewer says that the documentation does not support
that the requested services are required to be provided by an out of network provider. Our physician reviewer
found you have chronic right shoulder pain. The documentation does not support that the requested service is
emergent, urgent or that the in-network service would not be appropriate for or place the enrollee's medical
condition at risk. Therefore, the requested services can be provided by a network provider.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI scan have not been met.
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 an MRI scan. Therefore, we decided that the Plan does
not have to pre-approve a magnetic resonance imaging (MRI) scan to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the SPECT test, the medical supply, the stress test, or the echocardiogram provided from May 28, 2020, to June 4, 2020.
You asked the Plan to waive the copayments for the SPECT test, the medical supply, the stress test and the echocardiogram. You say that you believed all copayments were waived due to Covid-19. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical center), 20% coinsurance for each Medicare-covered medical supply, and a $10 copayment for Medicare-covered non-radiological diagnostic services. You have been asked to pay total of $244.34 for the SPECT test, the medical supply, the stress test and the echocardiogram. The SPECT test, the medical supply, the stress test and the echocardiogram fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 copayments for the SPECT test, the medical supply, the stress test, or the echocardiogram provided from May 28, 2020, to June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87498, 87502, 87503, 87634) provided on September 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you would like reconsideration because you performed all the tests that were ordered by the referring provider. The Plan denied your request. The Plan says they require utilization of network providers when possible and available and require authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergent situation, has been documented.
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 laboratory services (87498, 87502, 87503, 87634) provided on September 25, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the eyewear you received on November 18, 2020.
You asked the Plan to reimburse for the eyewear. The Plan denied your request. The Plan says you are responsible for the cost share.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once per year.
We looked at the file and the Plan's rules. The records show that the Plan has paid their portion for the eyewear you were provided on November 18, 2020. You are responsible for paying your share of the cost as outlined by your contract with the Plan. Therefore, we decided that the Plan does not have to reimburse for the eyewear you received on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 8,
2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this service was medically necessary.
The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when the criteria as listed
in the Rules section is met.
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 lumbar-sacral orthosis. Our reviewer
says that the requested orthosis was not medically reasonable and necessary. Our physician reviewer found the
totality of the case file does not provide sufficient evidence of a patient physician encounter that resulted in the
ordering of the orthosis. There is no provider claim submitted for the day of service. The documentation of the
service is insufficient to establish that a patient-physician encounter accorded.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested spinal cord stimulator.
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 a spinal cord stimulator. Our reviewer says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer found the enrollee has chronic bilateral foot pain. He has diabetic neuropathy. He has seen a naturopath. He does not have an evidence-based indication for a SCS trial. He was cleared for a trial by psychology. This enrollee does not have an evidence-based indication for a SCS trial. It is medically not necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services that you provided from June 2, 2020, through August 11, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there are no records of a referral from the member's PCP.

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 psychotherapy services. We found no exception that would require the Plan to pay for the psychotherapy services. Therefore, we decided that the Plan does not have to pay for psychotherapy services that you provided from June 2, 2020, through August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is motivated to improve and will tolerate
three hours of therapy. The Plan denied your request. The Plan says the enrollee does not require frequent
medical evaluations.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for a stroke and new onset atrial fibrillation. His
medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that he
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF. While the medical record supports a need for physical and occupational therapy, there is no documented
need for intensive rehabilitation services.
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient substance abuse treatment and drug testing services received .You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this provider is not eligible for Medicare.The Plan must follow Medicare rules. Medicare rules say that services mustbe provided by providers who are enrolled in the Medicare program.The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that would require the plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient substance abuse treatment and drug testing services received