Persius/hicric huggingface dataset:
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.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) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on June 25, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you feel like the Plan should pay more. The Plan denied your request. The Plan says the correct copayment 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 a $130 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay a $130 copayment for an MRI. Since an MRI was provided the correct copayment has been applied. An MRI falls within the outpatient diagnostic tests/diagnostic radiology 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 MRI provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered to the enrollee from July 19, 2019 to July 22, 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 services were unauthorized post-stabilization.
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 these services. Our reviewer says that the enrollee was stable for transfer to a network provider. Our physician reviewer found the enrollee presented to the emergency department (ED) on July 19, 2019 via ambulance after experiencing frequent falls. He was admitted for hypokalemia and alcohol intoxication. His vital signs were stable. There is no documentation necessitating post-stabilization care services after the ED evaluation. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered to the enrollee from July 19, 2019 to July 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq Tab 25MG.
You asked the Plan to pre-approve Myrbetriq Tab 25MG. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.
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 Myrbetriq Tab 25MG.
Benefits for Myrbetriq Tab 25MG 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit, skin graft, and MOHS surgery provided from September 30, 2019 to October 29, 2019.You asked the Plan to pay forthe surgical services. You say that the provider says the enrolleewas referred to your office for treatment. The provider also says that they billed the services with a GW modifier indicating that this visit was not related to the enrollee's hospice care.The Plan denied your request. The Plan says during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe office visit, skin graft, and MOHS surgery provided fromSeptember 30, 2019 to October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite (D2332) for tooth # 9 provided on October 9, 2019.
You asked the Plan to pay for the dental services. You say that you were advised the provider was an approved provider. You also say that this was an approved service. The Plan denied your request. The Plan says dental services are not covered when you receive the services out of network. The Plan also says that the provider in this case is out of network.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental service you received is not covered when you receive the service out of network. Therefore, we decided that the Plan does not have to pay for the resin based composite (D2332) for tooth # 9 provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0482) provided to the enrollee.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization and no medical records were submitted to show this testing was medically necessary or met the Medicare coverage criteria for this type of testing.
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from network providers. Medicare has specific coverage criteria for definitive drug testing. The contract with the Plan says that the Plan must 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. The Plan did not pre-approve this testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482) provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 10, 2019
You asked the Plan to pay for outpatient lab work. You say that these services were medically necessary. The
Plan denied your request. The Plan says there is no valid referral for this service.
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 outpatient lab work provided on September 10,
2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo solution to be taken at home.
You asked the Plan to pre-approve self-administered drugs. You say that it is inadvisable for the enrollee to
take oral medications, and she needs this drug to prevent further issues. The Plan denied your request. The Plan
says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and
the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that
the enrollee's Medicare Part D prescription drug benefits may be administered by the pharmaceutical provider.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Forteo solution to be taken
at home.
Benefits for self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from September 26, 2019 through September 27, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Ourreviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from September 26, 2019 through September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist/hand orthosis (L3916) knee orthosis (L1851) and suspension sleeve (L2397) provided  August 20, 2019 to August 21, 2019.You asked the Plan to pay forthe orthoses. You say that the records should support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, the documentation does not identify the enrollee's originating site at the time of the telehealth visit, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telemedicine and telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicarerules 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 forwrist/hand orthosis (L3916) knee orthosis (L1851) and suspension sleeve (L2397) provided  August 20, 2019 to August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve specialist service. You say that this provider is out-of-network but works in an in-network facility. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.
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-approve the medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on July 9, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you do not agree with the copayment because you were at the visit for less than 15 minutes and only your bandage was changed. 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 $40 copayment for each Medicare-covered office visit to other providers for urgently needed services. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you were assessed at the urgent care visit. 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 urgent care visit provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by out of network provider.
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 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 must 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 July 18, 2019 by out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on July 16,
2019
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There
are in-network providers that can render the services at issue.
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 outpatient mental health services provided on
July 16, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSNF care provided to the enrollee from August 5, 2019 through September 5, 2019.You asked the Plan to pay forSNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that 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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from August 5, 2019 through September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960), knee orthosis (L1812) and lumbar-sacral orthosis (L0650) provided to the enrollee on February 5, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported.
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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960), knee orthosis (L1812) and lumbar-sacral orthosis (L0650) provided to the enrollee on February 5, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the abdomen and pelvis for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no clinical need for the scan, as the MRI was performed within the 6-8 week period.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan.Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the plan acknowledges CT/MRI surveillance in this disease during the course of a change in treatment to be done every 6-8 weeks. The enrollee is still on chemotherapy and the last imaging study was 34 days ago (5 weeks). The requested exam should be approved because by the time it is scheduled and completed it will be 6 weeks after the most recent MRI scan.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the abdomen and pelvis for the enrollee.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information toreview. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.