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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the medical records, the enrollee would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitationtherapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the current condition. Medicare coverage criteria are not met. 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided at Aviara Health Care from August 7, 2019 to August 28, 2019. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were told that the insurance would cover the stay until August 28, 2019. 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 a $0 copayment for days 1-20 and a $140 copayment for days 21-100 for SNF care.  
 
You had a SNF stay from August 7, 2019 to August 28, 2019. You are not being charged a copayment for days 1-20 (August 7, 2019 to August 26, 2019). You are being charged a copayment for day 21 (August 27, 2019).  
 
You have been asked to pay a $140 copayment for a SNF stay. A SNF stay falls within the SNF care 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 a SNF stay provided at Aviara Health Care from August 7, 2019 to August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 23, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plandenied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 fordrug testing services provided to the enrollee on October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Computed Tomography (CT) of the Head (70450) provided on December 3, 2019.You askedthe Plan to pay forthe CT scan. You say that the service was medically necessary.The Plan denied your request. The Plan says the service was not preauthorized or emergent. There were network providers available to render the 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 forthe Computed Tomography (CT) of the Head (70450) provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upgraded electronics (electronic connection, expandable
controller and harness) and a seat lift.
You asked the Plan to pre-approve upgraded electronics (electronic connection, expandable controller and
harness) and a seat lift. You say that the requested seat lift (E2300), expandable controller (E2377), expandable
controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg
rests through the joystick are medically necessary. The Plan denied your request. The Plan says the requested
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control
power tilt, recline and power elevating leg rests through the joystick are not medically necessary. The Plan says
that a power seat elevation feature (E2300) is not covered by Medicare.
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 upgraded electronics (electronic
connection, expandable controller and harness) and a seat lift. Our reviewer says that the requested expandable
controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt,
recline and power elevating leg rests through the joystick are not medically necessary. Our physician reviewer
found the enrollee is with multiple sclerosis. A Group 3 power wheelchair with power tilt, recline and power
elevating leg rests were approved. The enrollee has 4/5 left upper extremity strength and 3+/5 right upper
extremity strength. The enrollee is able to perform grooming, bathing, dressing, cooking, and cleaning.
The pre-service request for electronic connection, expandable controller, and an expandable controller harness
is not medically necessary per Medicare criteria. The documentation does not reveal that the enrollee requires a
proportional input device, an attendant control, other electronic devices such as augmentative speech device, a
separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power
seating actuators through the drive control. The enrollee's strength is sufficient to control the power options
with their separate switches already included with the approval of these power options.
Furthermore, the requested power seat elevation feature (E2300) is not covered by Medicare because it is not
primarily medical in nature.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of upgraded electronics (electronic connection, expandable controller and harness)
and a seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve upgraded
electronics (electronic connection, expandable controller and harness) and a seat lift.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 7, 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 the records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from February 4, 2019
to February 6, 2019.
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says that
self-administered drugs are not covered.
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 pay for the self-administered drugs
provided from February 4, 2019 to February 6, 2019.
Benefits for the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on July 2, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records stating exactly what tests are to be performed.
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 G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on July 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered to the enrollee on May 4, 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 the claim has not been processed by the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan verified on January 16, 2020 that the primary insurer was effective May 13, 2007 to November 21, 2018. The Plan has not received an Explanation of Benefits from the primary insurer for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered to the enrollee on May 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says there is no network deficiency for the services and alternate providers were found.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 28, 2019 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 knee scooter crutch substitute (E0118).You asked the Plan to pre-approvea knee scooter crutch substitute. You say that you are not able to get around without this item.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutchsubstitutes with leg platforms.We looked at the file and Medicare rules. The item you have requested has been determined to not be medically necessary due to insufficient information that it is safe and effective. Based on this information, we decided that Medicare rules for coverage of a knee scooter crutch substitute have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee scooter crutch substitute (E0118).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (73610, 72141) provided on September 9, 2019.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not preauthorized or emergent.
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 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 services. Therefore, we decided that the Plan does not have to pay for the radiology services (73610, 72141) provided on September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on September 4, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to enrollee on September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for impacted ear wax removal (69209) provided on September 6, 2019.You asked the Plan to pay for the impacted ear wax removal. You say that you would like reconsideration as this service was medically necessary. The Plan denied your request. The Plan says CPT code 69209 may not be paid if furnished to a hospital inpatient or patient in a hospital outpatient department.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 69209 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 69209 has a PC/TC indicator of 5. This means that CPT code 69209 may not be paid if furnished to inpatient or outpatient hospital patients. This claim was billed with place of service code 23 for Emergency Department. Based on this information, we decided that Medicare rules for coverage of the impacted ear wax removal have not been met. Therefore, we decided that the Plan does not have to pay for impacted ear wax removal (69209) provided on September 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on July 5, 2019.You asked the Plan to waive the copayment for wound debridement. You say that you were informed your copayment was $5. You say that the Plan should pay some or all of the bill.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 $300 copayment for each Medicare-covered outpatient surgery service.You have been asked to pay a $300 copayment for wound debridement. Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 wound debridement provided on July 5, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have reached your 100 day limit this benefit period for SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 20, 2019 to March 30, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotics provided on October 28, 2019 by an out of network provider.
You asked the Plan to pay for the shoes and inserts. You say that prior authorization was not necessary for this procedure. 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 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 orthotics provided on October 28, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home-based phototherapy.You asked the Plan to pre-approve the home-based services. You say that this is medically necessary, as you don't want to risk going out due to COVID-19.The Plan denied your request. The Plan says medical necessity cannot be established for home therapy versus office-based therapy.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 the home-based services. Our reviewer says that the requested services are not medically reasonable or necessary in the home. Our physician reviewer found the documentation in the case file does not support that home-based phototherapy is medically necessary, as opposed to office-based phototherapy.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 home-based services have not been met.Therefore, we decided that the Plan does not have to pre-approve home-based phototherapy
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 23, 2019 and October 22, 2019.
You asked the Plan to pay for the nurse practitioner 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 from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. 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 nurse practitioner services provided on September 23, 2019 and October 22, 2019.