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

We decided that the Plan does not have to pay for a heart rhythm tracing, computer analysis, physician prescribed transmission of patient-triggered events greater than 24-hour electrocardiogram (EKG) up to 30 days (93229) provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a heart rhythm tracing, computer analysis, physician prescribed transmission of patient-triggered events greater than 24-hour EKG up to 30 days. You say that you provided the insured physician with the cardiac monitoring services in good faith and in accordance with policy terms. The Plan denied your request. The Plan says the provider and the referring provider are non-participating providers. The plan did not authorize any services for the provider or physician. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services were not considered urgent/emergent in nature. Prior authorization was not obtained as required under the Plan's benefits. Services rendered by non-participating providers, require prior authorization as outlined in the enrollees EOC.
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 a heart rhythm tracing, computer analysis, physician prescribed transmission of patient-triggered events greater than 24-hour electrocardiogram (EKG) up to 30 days (93229) provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 to the enrollee by an out of network (OON) provider.
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 services were rendered by a non-participating provider without prior authorization.
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 medical services provided on October 14, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision or needs acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 8, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged 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 $50 copayment for services obtained from a specialist, or under certain circumstances treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's 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 the specialist office visit provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe standard wheelchair rental provided on August 13, 2019 by an out of network provider. You asked the Plan to pay forthe standard wheelchair rental. You say that the Plan should pay for the medically necessary services.The Plan denied your request. The Plan says prior authorization was not requested.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 itemat issue in this appeal. The Plan did not pre-approve the itemat issue. We found no exception that would requirethe Plan to pay for this item.Therefore, we decided that the Plan does not have to pay forthe standard wheelchair rental provided on August 13, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periapical first x-rays (D0220) and periapical additional x-rays (D0230) provided December 2, 2019.You asked the Plan to pay for the dental x-rays. You say that you never asked for the x-rays and you are not going to pay for it.The Plan denied your request. The Plan says the requested service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Per the health plan contract only bitewing x-rays are listed as a covered benefit.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for periapical first x-rays (D0220) and periapical additional x-rays (D0230) provided December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care so that she can regain function, ambulate safely, perform activities of daily living, and return home/to her community with improved quality of life. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azopt.
You asked the Plan to pre-approve Azopt. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Azopt is not covered under the enrollee's Medicare Part B benefit.
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 Azopt.
Benefits for Azopt may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wheelchair purchased from on October 7, 2019.
You asked the Plan to reimburse you for the lightweight wheelchair. You say that because of your injury you could not walk without assistance The Plan denied your request. The Plan says the supplier is not Medicare certified.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the wheelchair on October 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the lab tests. You say that these tests are medically necessary to stop your condition from spreading. The Plan denied your request. The Plan says your records do not indicate that you have an emergent or urgent medical condition, or are in need of specialized services that are not available in network.
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 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-approve the medical services to be provided by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network providers available to you that can provide the care you are requesting. 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 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-approve the physician services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEpogen for the enrollee.You asked the Plan to pre-approveEpogen. You say that this is medically necessary.The Plan denied your request. The Plan says that step therapy criteria have 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 Epogen. Our reviewer says that Epogen is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Retacrit (Epoetin alfa-epbx) or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Epogen.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of Epogen have not been met.Therefore, we decided that the Plan does not have to pre-approveEpogen for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 PWC and accessory items.
You asked the Plan to pre-approve the PWC and accessory items. You say that you cannot move around in the manual wheelchair that you have now and need someone to push you around all the time. The Plan denied your request. The Plan says the medical records do not substantiate that medical necessity guidelines have been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 PWC and accessory items. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no clear evidence that the enrollee is unable to operate a manual WC or that a manual WC does not allow her to overcome deficits in MRADLs. Therefore, the use of a motorized WC is not shown to be medically 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 the PWC and accessory items have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 PWC and accessory items.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 the enrollee was admitted to acute care on 2/7/20 for congestive heart failure exacerbation and coronary artery bypass graft evaluation. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory care with ventilator support, sedation, surveillance laboratory studies, tube feedings, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 5, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says A review has been completed and it has been determined that the denial of CPT code 99213 on April 5, 2019 is appropriate. This rule identifies procedure codes billed by the same provider within a procedure's post-operative period. When a substantial diagnostic or therapeutic procedure is performed, the evaluation and management service is included in the global surgical period as defined by CMS. Procedures that are assigned a 90-day global surgery period are designated as major surgical procedures; those assigned a 10-day or 0-day global surgery period are designated as minor surgical procedures. The guidelines state CPT Code 17260 has a global surgery period of 10 days. Evaluation and management services, submitted with minor surgical procedures, on the same date of service or during the 10-day post-operative period, are not recommended for separate reporting because they are part of the global service. The modifier 24 indicates that an "unrelated" evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. However, some of the diagnosis codes are the same on both claims and does not indicate the enrollee was seen due to a reason unrelated to the original procedure (17260). Therefore, procedure 99213 is not recommended for separate reimbursement when submitted with procedure 17260. The same provider (specialty 03, dermatology) provided both services, the surgical procedure on April 1, 2019 and the office visit on April 5, 2019.
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, this claim cannot be paid due to its relationship to services previously provided to the enrollee within the global surgery period. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay at the Hospital on October 18, 2019.
You asked the Plan to waive the copayment for an observation stay. You say that you met the MOOP amount of $6,700.00. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 the MOOP amount for 2019 is $6,700. Your contract with the Plan also clearly says that you must pay a $400 copayment for observation services. You had an observation stay on October 18, 2019. The record shows that due to the reprocessing of a claim, you had only paid $6,650 MOOP amount. Therefore, you are responsible to pay $50, which is less than the total copayment amount for observation services. You have been asked to pay $50 for an observation stay. An observation stay falls within the outpatient hospital services 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 an observation stay at the Hospital on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 22, 2019 to the enrollee by an out of network (OON) provider.
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 services were rendered by a non-contracted provider without prior authorization.
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 medical services provided on October 22, 2019 to the enrollee by an out of network (OON) provider.