Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include oxygen supplementation, oral steroids, surveillance laboratory studies, close fluid monitoring, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 87798 and 87481 provided on June 20, 2019.
You asked the Plan to pay for CPT codes 87798 and 87481. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules say there is limited coverage for procedure codes 87798 and 87481 and ICD-10 Codes L60.1, L60.3, and B35.1 are not covered diagnostic codes for these services. Based on this information, we decided that Medicare rules for coverage of CPT codes 87798 and 87481 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 87798 and 87481 provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99252 provided on April 11, 2019.
You asked the Plan to pay for CPT code 99252. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 99252 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for CPT code 99252 provided on April 11, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional private duty nursing (PDN) hours per day for two months. You asked the Plan to pre-approve these services. You say that the enrollee needs more services.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 a tracheostomy and feeding tube and is receiving 24-hour private duty nursing. His skilled care needs are minimal, including ulcer care and trach suctioning. The plan has approved eight hours of daily nursing care. The approved hours are sufficient to meet the enrollee's needs, and the requested eight additional hours per day are 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 pre-approve eight additional private duty nursing (PDN) hours per day for two months.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an FDG Positron Emission Tomography (PET) scan (78608). You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the PET scan is not medically necessary. Our physician reviewer found there were not focal findings on physical examination. The enrollee underwent an MRI of the brain noting mild chronic microvascular ischemia, but otherwise negative. The records support the provider thinks symptoms are related to medications. Without the support of the documentation, NCD criteria are not supported 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 PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approve an FDG Positron Emission Tomography (PET) scan (78608).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary in this case. You have not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer found that your condition does not meet criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 26, 2019.You asked the Plan to pay for the nurse practitioner services. 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 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 August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on August 20, 2019.You asked the Plan to waive the copayment for urgent care services. You say that urgent care didn't do anything but tell you to the go the ER.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 $50 copayment for urgently needed services.You have been asked to pay a $50 copayment for urgent care services. Since an urgent care visit was provided, the correct copayment has been applied. Urgent care services fall within the urgently needed services/within the U.S. 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 urgent care services provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the power wheelchair. You say that you had spine surgery and have lifetime pain. You say that you have fallen with your cane and are unable to manage your pain. You say that you have difficulties taking care of yourself. You say that the walker is not enough for the mobility you need daily. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. The plan says that the enrollee's mobility deficit within the home can be resolved with a front wheel walker. The plan says that the enrollee received a front wheel walker on September 6, 2019.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the power wheelchair. Our reviewer says that the requested power mobility device is not medically necessary. Our physician reviewer found the enrollee is reported to be independent for bed mobility and transfers, and history is notable for chronic pain, lumbar spine surgery, and hypertension. Our physician reviewer found that, while the enrollee does have mobility and mobility related activities of daily living deficits, the records do not indicate that the use of a cane or walker could not safely and adequately address ongoing symptoms. 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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 28, 2019 through August 4, 2019.You asked the Plan to pay for the home infusion therapy. You say that S9328 is a valid code per CMS. The Plan denied your request. The Plan says S9328 has a status code of I which is invalid for Medicare purposes.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 S9328 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status indicator of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 28, 2019 through August 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by out of network provider.You asked the Plan to pay for lab work. You say that the provider is contracted with the facility. You say that the patients do not have the option of choosing whom they see for lab services.The Plan denied your request. The Plan says there are in-network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 9, 2019.
You asked the Plan to pay for the nurse practitioner services. 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 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 August 9, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve companion/custodial home care.
You asked the Plan to pre-approve companion/custodial home care. 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 must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 companion/custodial home care. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee requires 24-hour care due to hemiparesis from a cerebrovascular accident. The enrollee was recently treated for a urinary tract infection. The enrollee uses a wheelchair for mobility. The documentation does not support that the enrollee meets criteria for coverage of the requested companion/aide. The enrollee is not currently receiving any skilled nursing or skilled therapies. The records do not support the home health aide services are reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. The enrollee's needs are custodial 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 companion/custodial home care have not been met. Therefore, we decided that the Plan does not have to pre-approve companion/custodial home care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided on July 8, 2019.
You asked the Plan to pay for genetic test. You say that this test was ordered by the enrollee's treating physician because it was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not considered medically necessary and is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that oncology (prostate) gene expression profile testing was not considered medically necessary and was not covered by Medicare for date of service July 8, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided on July 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ambulance ride provided on May 10, 2019.
You asked the Plan to reduce the copayment for the ambulance ride. You say that the service should be covered as in-network because the ambulance was arranged by your in-network doctor. 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 Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $275 copayment for the ambulance ride. The ambulance ride falls "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 reduce the copayment for the ambulance ride provided on May 10, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on June 19, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the provider needs to bill Original Medicare for the services provided.
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 the lab services provided to the enrollee on June 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, and first intraoral periapical x-ray provided on September 13, 2019.
You asked the Plan to pay for the core buildup and x-ray. You say that you feel that these services should be covered under your comprehensive dental coverage under your plan. The Plan denied your request. The Plan says core buildup, including any pins when required, is not considered a dental filling. The Plan also says that these services are not eligible for coverage under your comprehensive dental 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 core buildup, including any pins when required, and first intraoral periapical x-ray provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99153) provided to enrollee on April 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments. We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 under the OPPS when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the services (CPT 99153) provided to the enrollee on April 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the spine x-ray, the set up, and the transportation of the x-ray provided on August 2, 2018 by out of network provider.
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician. The Plan also says the services were not urgent 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 spine x-ray, the set up, and the transportation of the x-ray provided on August 2, 2018 by out of network provider.