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

We decided that the Plan does not have to pay for assisted living services provided by an out of network (OON) provider.

You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 assisted living services provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS non-emergency ambulance (A0428) provided August
31, 2020

You asked the Plan to pay for the ambulance service. You say that please review your appeal based on the
medical necessity criteria listed, along with the enclosed medical documentation and consider your claim for
payment. The Plan denied your request. The Plan says the medical documentation does not support that this
service was medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 ambulance service. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee requested ambulance services to transport her to the hospital for radiation
therapy appointment. It was reported that she was week. Vitals stable. The documentation does not support that
a stretcher van would be contraindicated for this enrollee. The documentation does not support the enrollee
needed expertise and special equipment during transportation to her appointment. The records do not
sufficiently support the use of ambulance transport.

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 ambulance service have not been met. Therefore, we decided that the Plan
does not have to pay for BLS non-emergency ambulance (A0428) provided August 31, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that the instability in your hips make it difficult to do activities of daily living. The Plan denied your request. The Plan says you are medically stable, with no acute skilled therapy needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist to minimal assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
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 stay is 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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing supervision in an IRF. While you may benefit and participate in multiple therapies your functional level does not require or appear to be able to tolerate therapy on an intensive rehabilitation therapy program provided 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-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride.

You asked the Plan to waive the copayment for the ambulance ride. You say that you were assured that everything was taken care of and it was a medical necessary to be transported to the rehab. 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 $275 copayment for each in- and out-of-service one-way Medicare-covered ambulance transport. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for the ambulance ride.

You have been asked to pay a $235.46 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 the ambulance ride.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) provided on September 25, 2020.

You asked the Plan to pay for the dental services. You say that you had an ongoing infection that would not go away. You say that you had a root canal. You say that you were not told that the root canal would not be covered. You say that you thought that this was what preventative care was all about taking care of this kind of thing affecting your health. You also say that you would like the root canal to be covered as the cost is less expensive than a crown and you could not put a crown on over an infected tooth. The Plan denied your request. The Plan says the root canal is not listed as a covered service.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excess skin removal.

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 cosmetic in nature and not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that excess skin removal is covered when specific
criteria are 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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee previously underwent
abdominoplasty and had a great deal of excessive skin along the sides and extending onto her back. Evidence
of chronic skin rashes, skin irritation, and skin breakdown are noted. Topical steroids and antibiotic ointment
were used with little to no relief. The documentation does not support that the enrollee's skin abnormalities
consistently recurred over three months while receiving appropriate medical therapy or remained refractory to
appropriate medical therapy over a period of three months. The services do not meet the criteria for coverage
and were not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the excess skin removal.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 31, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services were not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the requested ambulance services are not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 90-year-old male who was confined to the bed with muscle wasting and a congenital heart malformation. Ambulance services were requested to go to a doctor's visit. Ambulance services arrived with the patient alert with normal vitals but unable to ambulate. Other forms of transportation were not noted to have been contraindicated for this enrollee. A stretcher van would have been more appropriate. The enrollee did not require acute care and did not require trained EMS or special equipment during the transfer. The documentation does not support the enrollee requiring ambulance services on August 31, 2020. 

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 31, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on August 5, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that these services have not been reported correctly.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for the laboratory services by a contract provider. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services is considered approved by the plan. Additionally, the records do not substantiate the Plan's reason for denial. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the laboratory services provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid based on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained.

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 physician services provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy bra (L8000).

You asked the Plan to pre-approve the services. You say that there is no reason why this should not be covered now. The Plan denied your request. The Plan says the records do not show a covered mastectomy form or silicone breast prosthesis.

The rules say that a mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis. 

The case file does not show that the criteria has been met, as there is no evidence of a mastectomy form or silicone breast prosthesis. 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 a mastectomy bra (L8000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee pain of uncertain etiology. There is no evidence that a trial block has been performed. There is no diagnosis of osteoarthritis and no evidence of failure of conservative treatments. The requested genicular nerve ablation is considered experimental in nature and not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the irrigation and removal of multiple
blood clots from bladder and bladder canal using an endoscope.

You asked the Plan to waive the copayment for the outpatient surgery. You say that this surgery was only
required due to complications from a previous surgery. The Plan denied your request. The Plan says your
surgery was performed in an outpatient hospital facility therefore the correct cost share 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 $325
copayment for outpatient surgery.

You have been asked to pay a $325 copayment for the irrigation and removal of multiple blood clots. The
irrigation and removal of multiple blood clots falls within the outpatient surgery 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 irrigation and removal of multiple blood clots from bladder and
bladder canal using an endoscope.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are
receiving adequate rehab in the inpatient rehab facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that from a nursing perspective, you received enteral nutrition, and had stable vital signs. Regarding
rehab services, you are at a supervision to contact guard assist level with functional mobility. You require
varying assist with activities of daily living. You have ongoing dysphagia and aphasia. Although there are
identifiable skilled nursing and skilled therapy service needs, you do not require skilled services on a daily
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulatory skin surgery.

You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (15839). You say that the enrollee has excess lip tissue from a medical condition and would benefit from this procedure. The Plan denied your request. The Plan says they do not see additional surgery is needed for function of lip or mouth.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

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 excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (15839). Our reviewer says that the service is not medically necessary. Our reviewer found the physical exam documents that the lips, mucosa, and tongue are "normal". The documentation does not support at the requested excision of excessive skin and subcutaneous tissue of the lip is medically reasonable and necessary for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (15839) have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulatory skin surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when
required (D2950), indirect pulp cap (D3120), antimicrobial agents (D4381), and problem focused limited oral
evaluation (D0140) provided from June 24, 2020, to July 10, 2020.

You asked the Plan to pay for the crown, core buildup, indirect pulp cap, antimicrobial agents, and problem
focused limited oral evaluation. You say that the provider told you that these services would be covered. The
Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not
contact the Plan in regard to your cost share or provider questions prior to receiving the above referenced
services.

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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown
(D2740), core buildup, including any pins when required (D2950), indirect pulp cap (D3120), antimicrobial
agents (D4381), and problem focused limited oral evaluation (D0140) provided from June 24, 2020, to July 10,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation
(92014) rendered by the out of network (OON) provider on October 5, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
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 the ophthalmological medical examination and evaluation (92014) rendered by the out
of network (OON) provider on October 5, 2020.