Persius/hicric huggingface dataset:
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 care can be received in another setting.
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's medical conditions appear stable. There are no complex wound care
needs. He does not require medical oversight of his condition at an acute hospital level of care. The enrollee is
ambulating household distances and does not require an intensive rehabilitation therapy program. The enrollee
is limited by pain and weakness. He would not be expected to be able to fully participate in or benefit from the
required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive
rehabilitation therapy program would significantly impact the enrollee's condition differently compared with
therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF level.
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 pay for physician's services provided on August 22, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care fromnetwork 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 these services. Therefore, we decided that the Plan does not have to pay for physician's servicesprovidedon August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on September 18, 2018.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was
medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
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 the shoulder-elbow-wristhand
orthosis provided on September 18, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 9190) provided to E. Burnett on August 9, 2019.You asked thePlan to pay forthe services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on August 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (90832) provided on May 9, 2019 by the out of
network provider.
You asked the Plan to pay for psychotherapy. You say that your provider cannot deny any medical
services that are essential for patient health treatment. You say that you are requesting a review of the charges
and retro-authorize payment for the claim. The Plan denied your request. The Plan says services were not
authorized because the provider is a non-network provider who does not work with the member's
health plan, and the member self-directed for services. The Plan also says that no prior authorization for any
services were noted and the member's primary care physician did not refer for these services. No medical
necessity for an out-of-network provider, such as an urgent or emergency 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 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 psychotherapy (90832) provided on May 9, 2019
by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 10, 2019 to October 29, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 10, 2019 to October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing test provided on August 6,
2019.
You asked the Plan to waive the copayment for the hearing test. You say that this hearing test was supposed to
be free. You say you were not told the provider was out-of-network. 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 $75
copayment for each out-of-network Medicare-covered exam.
You have been asked to pay a $75 copayment for the hearing test. The hearing test falls within the "Hearing
Services" benefit category. The record shows a diagnosis of conductive and sensorineural hearing loss.
Therefore, the hearing test is diagnostic in nature.
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 hearing test provided on August 6, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvecomputed tomography angiography (CTA) services.You asked the Plan to pre-approvethe CTA services. You say that the CTA is necessary to evaluate for a mass.The Plan denied your request. The Plan says that the clinical information shows that the same testor one similar to the requested study was previously performed. The Plan says that the results of this prior image do not show why the results were not sufficient for the evaluation of the current clinical condition.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 wascorrect in denying the request to pre-approve the CTA services. Our reviewer says that the requested CTA is medically reasonable and necessary. Our physician reviewer found the enrollee is a 77-year-old woman with biliary and pancreatic duct dilation. A CT scan in October of 2019 could not rule out an ampullary mass. An ERCP with biopsy was benign and a stent was placed. A repeat ERCP for removal of stent was performed in January of 2020. The findings included a persistent filling defect. A CTA was orderedfor 3-month follow up of possible pancreatic mass. The requested test is reasonable to assess for possible progression given that there are persistent radiographic abnormalities concerning for pancreatic mass.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 CTA services have been met.Therefore, we decided that the Plan has to pre-approvecomputed tomography angiography (CTA) services.If the Plan does 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 to review. The Plan has to show us the mistake and/or send us the new information. This does nothappen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided on August 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not coded correctly.
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, the CPT Code Manual definition of code 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. 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 for oxygenator assembly and operation services (CPT 99190) provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on August 16, 2018.
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 procedure code 95999 is not supported.
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, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows
that train of four testing was performed and there is a more appropriate code for these services. 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 services rendered on August 16, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 11, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you did not have a say in the transport following your hospital discharge. You say your wife was going to take you to your inpatient rehabilitation facility. 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 $250 copayment for each Medicare-covered one-way trip via ground ambulance. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the ambulance ride.
You have been asked to pay a $248.13 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows you received the ambulance transport.
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 on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan doesnot have to pre-approveoffice visits (99214, 99213, 99212, 99215) to be provided by an out of network provider.You asked the Plan to pre-approveoffice visits. You say that you are scheduled for back surgery on January 21, 2020 and January 23, 2020 and must receive clearance from her cardiologist prior to having surgery. You say you have been seeing your doctor for several years and he has all of your medical history records. You also say that you cannot reschedule the surgeries in January due to the fact that your spine is being compressed and if you have any type of injury you risk death.The Plan denied your request. The Plan says you must use network providers to get your medical care and services. The Plan says that the only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services and cases in which the plan authorizes the use of out-of-network providers. The Plan also says that if you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, then you can get this care from an out-of-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 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-approveoffice visits (99214, 99213, 99212, 99215) to be provided by your out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation therapy provided on July 23, 2019.
You asked the Plan to pay for radiation therapy. You say that the claim has not been paid in full or under the terms of the contract. You say that payment should be made. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 for radiation therapy provided on July 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided by on
June 24, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that there was no need for
you to be sent to the hospital. You say that the bill is unnecessary. The Plan denied your request. The Plan says
the copayment applied correctly.
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 $175
copayment for Medicare-covered ground ambulance benefits. The copayment applies per trip of an ambulance
request.
You have been asked to pay a $175 copayment for the ambulance transport. The ambulance transport 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 transport provided by on June 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on October 4, 2019.
You asked the Plan to waive the deductible for laboratory services. You say that you have blood work done every six months. You say that you have not been charged. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Laboratory services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to laboratory services. This cost sharing is a contractual obligation that had not been met at the time laboratory services were received on October 4, 2019. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on October 4, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic exercises (97110) to be provided by the out of
network provider.
You asked the Plan to pre-approve therapeutic exercises. You say that your rotator cuff surgery is scheduled for
December 18, 2019 and then you will be leaving for Arizona shortly after around the first or second of January.
You say that you will not be able to attend the physical therapy appointments unless they are approved for out
of state because you live in Arizona during the months of January through March. The Plan denied your
request. The Plan says the provider is outside the Plan's service area. The
Plan says there is no medical reason you cannot get this care within network. The Plan also says that care would not be referred to this site unless care needs were urgent or
emergent or if care needs could not be met within the Plan system.
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
therapeutic exercises (97110) to be provided by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cochlear device and implantation.
You asked the Plan to pre-approve a cochlear device and implantation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that cochlear devices are only covered for certain indications. 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 cochlear device and implantation. Our reviewer says that the requested cochlear device is not medically reasonable or necessary. Our physician reviewer found the enrollee has had bilateral sensorineural hearing loss for 15 years. The enrollee has tried and not improved with bilateral hearing aids. The enrollee was noted to not be doing well with hearing aids in
September 2019. The hearing test showed mild to profound sensorineural hearing loss bilaterally. The enrollee scored better than 40% on multiple open set hearing tests that were done under the best aided conditions. Cochlear implantation may be covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 40% correct in the best-aided listening conditions. The enrollee scored better than 40% on the multiple open set hearing test that were done under the best aided conditions. Therefore, the enrollee does not meet criteria for the requested cochlear implantation. 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 cochlear device and implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve a cochlear device and implantation.