Persius/hicric huggingface dataset:
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-approve the additional pain management services. You say that the member has established care and confidence in your providers and has received significant relief in your care. The Plan denied your request. The Plan says there are no extenuating circumstances related to geographic access, reasonable continuity of care or unique medically recognized qualifications of the requested out of network provider to justify prior authorization of out of network benefits beyond the transition of care allowance.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-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 22 to October 23, 2019 by provider.You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to be observation level. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. Inpatient care services were not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided October 22 to October 23, 2019 by provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 25, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We find that labs are not supported in the medical record. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis, or a specific treatment strategy for disease or illness present in the enrollee at the time of service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF 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 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that these services were medically necessary. You say that without this care it could result in wound complications. The Plan denied your request. The Plan says no prior authorization was 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 pay for wound care provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) and a lumbar-sacral orthosis (L0650) provided to the enrollee on September 17, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a wrist-hand orthosis (L3916) and a lumbar-sacral orthosis (L0650) provided to the enrollee on September 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for one physical therapy visit an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this service can be provided internally.
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-approve
a referral for one physical therapy visit
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dentures. You say that the enrollee has had the current partials for 20 years. You say that the enrollee would like complete dentures to replace them. The Plan denied your request. The Plan says dentures are not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental items are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diltiazem ER for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must 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 Plan does not have to pre-approve Diltiazem ER for the enrollee.
Benefits for this drug 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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the allergy injection (95117) on October 23, 2019. We decided that the Plan does not have to reduce the coinsurance for the allergy injection (95165) on November 20, 2019.
You asked the Plan to reduce the coinsurance for the allergy injections. You say that your patient responsibility for your allergy injections has been $1.99. You say your responsibility has increased. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to waive the coinsurance for the allergy injection (95117) on October 23, 2019.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the code 95117 is a professional service for allergen immunotherapy and that the code is for the administration of the injection only. The allergy injection (95117) on October 23, 2019 falls within the "Allergy shots and serum" benefit category.
The Plan says that you must pay $2.54 for the allergy injection (95117) on October 23, 2019. Based on the plan contract, however, you cannot be asked to pay more than a $0 for the administration of the allergy injection. Therefore, we decided that the Plan has to reduce the coinsurance for the allergy injection (95117) on October 23, 2019 from a coinsurance amount of $2.54 to a $0 copayment. Therefore, we decided that the Plan has to reduce the coinsurance for the allergy injections.
We also decided that the Plan does not have to reduce the coinsurance for the allergy injection (95165) on November 20, 2019.
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 the allergy injections. You have been asked to pay $32.34, which is less than the standard copayment amount for the allergy injection (95165) on November 20, 2019. The allergy injection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the allergy injection (95165) is considered a professional service. Therefore, we decided that the Plan does not have to reduce the coinsurance for the allergy injection (95165) on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an under mattress grab bar (E1399).You asked the Plan to pre-approvea grab bar. You say that the grabbar is medically necessary.The Plan denied your request. The Plan says grab bars are not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar 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-approvean under mattress grab bar (E1399)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you feel the enrollee was not kept in long enough which is why he has been in and out of the hospital.The Plan denied your request. The Plan says the enrollee did not meet the qualifications of the mandatory three-day inpatient hospital requirement for coverage into a SNF.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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $189.01 cost share for lab services provided on March 26, 2019 and applied to the 2019 yearly $300 deductible.You asked the Plan to waivethis cost share. You say that there should be no charge for this service.The Plan denied your request. The Plan says the lab services provided are not among those exempt from the deductible. The Plan says that these charges were applied to the deductible based on the services provided and the Plan contract agreement.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 there was a $300 deductiblefor 2019. The Plan has followed Medicare rules by clearly disclosing in the contract that there was a $300 for deductible. This cost sharing is a contractual obligation that had not been met at the time this was provided. Therefore, we decided that the Plan does not have to waivethe $189.01 cost share for lab services provided on March 26, 2019 and applied to the 2019 yearly $300 deductible.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 12, 2019, to June 14, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that The Plan denied your request. The Plan says that this was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the ED on June 12, 2019. At that time, the enrollee was reported to have anorexia and found to have pneumonia, dehydration, AKI and electrolyte abnormalities. The documentation indicates a reasonable belief that, at the time of admission, two midnights of care would be required to further evaluate and treat the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 12, 2019, to June 14, 2019.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 not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors for the enrollee.You asked the Plan to pre-approvethese services. You say that this is medically necessary for the enrollee.The Plan denied your request.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that thePlan does not have to pre-approveFreestyle Libre 14 day sensors for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve18 additional ambulance service trips from residence to doctor's office.You asked the Plan to pre-approve18 additional ambulance service trips. You say that the enrollee is bed bound and needs ambulance transportation to doctor appointments.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pre-approve18 additional ambulance service trips from residence to doctor's office.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided by provider, on November 3, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges.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 $40 copayment per visit for specialty care services. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 decidedthat the Plan does not have to waive the copayment fora specialist visit provided by provider, on November 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 30, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 September 30, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring supplies (HCPS A4557) provided to the enrollee on April 10, 2019. You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says no separate payment is made for this. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code A4557 is "lead wires (neuromonitoring supplies)." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the supplies. Our reviewer says that the
services at issue in this case were not coded correctly. Our physician reviewer found pr Medicare guidelines, HCPCS code A4557 is a Bundled/Excluded Code. If HCPCS code A4557 is incidental to the physician service, it is not separately payable. 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 supplies have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring supplies (HCPS A4557) provided to the enrollee on April 10, 2019.