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

We decided that the Plan does not have to pay for the medical services provided on August 13, 2019 by an out of network (OON) provider.You asked the Plan to pay for the EKG (93005). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 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 the medical services provided on August 13, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care you received on August 30, 2019, and September 9, 2019.
You asked the Plan to waive the copayment. You say that you should not have a copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $120 copayment for emergency care. Review of the file shows that you received emergency care on August 30, 2019, and September 9, 2019. You have been asked to pay a $120 copayment for each emergency visit. The services fall within the emergency 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 the emergency care you received on August 30, 2019, and September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided by on May 2, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided by on May 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital facility fee provided by provider from March 1, 2019 to July 12, 2019.You asked the Plan to waive the copayment for the outpatient hospital facility fee. You say that you should not be responsible for the copayment. 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 Medicare-covered outpatient hospital and observation services. You have been asked to pay a $275 copayment for the outpatient hospital facility fee. The outpatient hospital facility fee falls within the "Outpatient hospital 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 outpatient hospital facility fee provided from March 1, 2019 to July 12, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says care can be provided in the current inpatient 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for a viral respiratory infection and COPD exacerbation. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 Plandoes not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Planhasto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approveSNF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthatcare can be received in another setting.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 care. Our reviewer says that the requested admission is medically reasonable and necessary. Our physician reviewer found the enrollee requires oversight of her medical conditions and medication management. She has cognitive impairment and is not expected to be able to adjust medications or self-monitor her medical conditions. She is at risk for secondary complications of immobility such as pressure ulcers and contractures. She is receiving intravenous medications. The enrollee has not returned to her prior level of function. She had previously been cared for at home and now requires assistance of more than 1 person for essential activities of daily living such as bed mobility and transfers. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The enrollee requires both daily skilled therapy and nursing services. She is unable to perform essential activities of daily living such as bed mobility without assistance of more than one person. She has daily skilled nursing needs. The enrollee was previously cared for at home. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care being requested.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Planhas to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for practitioner visit. You say that the nursing facility requested this service; therefore, medical necessity is established to provide service.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 payforthe medical services provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 4, 2019.You asked the Plan to pay for the pump operation and assembly. You say that it takes a half hour to to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on January 29, 2019.You asked the Plan to pay forlab tests. You say that you are appealing with additional documentation.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action.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 forlaboratory testing provided on January 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on August 6, 2018.You asked the Plan to pay for surgical services. You say that these services are eligible for payment to a physician assistant.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for surgical services was not filed until September 20, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for surgical services provided on August 6, 2018.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Victoza 3-pak.You asked the Plan to pre-approve the Victoza. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B.The Planmust follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plandoes not have to pre-approve Victoza 3-pak. Benefits for the Victoza may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services are available from network providers.Medicare rules say that plans canrequire 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 care that cannot be provided by network providers.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 Plandoes not haveto pre-approvea referral to an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300).You asked the Plan to pre-approvea power seat elevation feature. The Plan denied your request. The Plan says that a power seat elevation feature is non-covered because it is not primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a porcelain crown for tooth #30.You asked the Plan to pre-approve the crown. You say that this treatment is necessary for the enrollee's condition.The Plan denied your request. The Plan says that the documentation does not show a significant breakdownof the coronal structure of the tooth to warrant a crown.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. The Plan covers the crown when the services are medically necessary and reasonable.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 crown. Our reviewer says that the documentation supports the necessity of the requested crown. Our physician reviewer found a review of the patient's dental record and radiograph indicates that a large alloy restoration is present in the tooth and a complete fracture of the mesio-buccal cusp has occurred. A significant portion of the tooth is compromised which makes the placement of a crown to restore the integrity of the tooth reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met.Therefore, we decided that the Plan has to pre-approvea porcelain crown for tooth #30.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 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 skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says shower chairs are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sex transition surgery (55980), the insertion of testicular prosthesis (54660), and a muscle-skin graft (15734).You asked the Plan to pre-approve sex transition surgery, the insertion of testicular prosthesis, and a muscle-skin graft. You say that this is needed for a medical problem.The Plan denied your request. The Plan says reversal of gender affirming surgery for gender dysphoria is considered 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 sex transition surgery, the insertion of testicular prosthesis, and a muscle-skin graft. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while it is regrettable that you have had a change of heart regarding your initial surgery, that surgery was performed with a clear understanding that it was irreversible. There is no evidence that you are unable to urinate. You are able to take male hormone replacement. Reconstruction of a phallus is not considered to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sex transition surgery, the insertion of testicular prosthesis, and a muscle-skin graft have not been met.Therefore, we decided that the Plan does not have to pre-approve sex transition surgery (55980), the insertion of testicular prosthesis (54660), and a muscle-skin graft (15734).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out of network medical services. You say that you want to go out of network to see pain management provider because he can prescribe your medications and because he performs injections on the x-ray table. You say that you saw in network provider and she did not perform the injections on the x-ray table. Yousay that you have already paid out of pocket for 1 visit to and that he told you all doctors should be doing injections on the x-ray table.The Plan denied your request. The Plan says there are in-network specialists available in the enrollee's area who can provide the standards of care for treatment of the enrollee's condition.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 care that cannot be provided by network providers.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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 20, 2019.You asked the Plan to pay for the drug testing. You say that this test is medically necessary to help the physician to determine compliance with the prescription plan. 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 and the referring provider are not network providerswith the Plan. The Plan did not pre-approve the drug testing.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 drug testing provided on August 20, 2019.