Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428) provided on September 22, 2020.
You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you do not understand why you have to pay. The Plan denied your request. The Plan says the copayment was 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for non-emergency ambulance transportation. The service at issue falls within the ambulance services benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428) provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve RFA services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says criteria have not been met for the requested services.
The Plan follows Medicare rules. Medicare rules say that if an extended amount of time has passed since the last RFA procedure, diagnostic procedures must be repeated. 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 RFA services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 79-year-old woman who has chronic low back pain. She had the requested RFA services 5years ago and requests a repeat of the L2-L5 RFA. She had 2 years of pain relief, but the pain has now returned. No recent diagnostic blocks have been performed. The request exceeds utilization limits, and the diagnostic blocks should be repeated to delineate the two levels that need to be blocked. The request is deemed not medically reasonable or 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you want three hours of therapy and constant attention from a physician. The Plan denied your request. The Plan says you are not able to tolerate 3 hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that you were admitted to the acute care hospital for peripheral arterial disease. Your medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 8,
2020.
You asked the Plan to pay for a limited oral evaluation. You say that you thought the provider was in-network.
The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 a limited
oral evaluation (D0140) provided on December 8, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical services described by current procedural terminology (CPT) code 29880 provided on December 15, 2020.
You asked the Plan to pay for CPT code 29880. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that this is a bundled service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment for CPT code 29880 as being bundled into payment for CPT code 29879. The Plan has not provided any Medicare documentation confirming that CPT codes 29880 and 29879 cannot be separately billed and paid for. Therefore, we decided that the Plan has to pay for the surgical services described by current procedural terminology (CPT) code 29880 provided on December 15, 2020.
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 5,
2020 by an out of network provider.
You asked the Plan to pay for subsequent nursing facility care (99308). You say that the provider depends upon
the hospital staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says
authorization for out of network services 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 5, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on September 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for durable medical equipment. You say that you would like this processed as in-network. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.
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 had network providers available who could have provided 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 durable medical equipment provided on September 12, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prostatic Urethral Lift procedure.
You asked the Plan to pre-approve Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant (52441) and Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) (52442). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says a prostatic urethral lift is not indicated for patients with urine obstruction and prostate cancer.
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 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant (52441) and Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List
separately in addition to code for primary procedure) (52442). Our reviewer says that the requested
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the use of the device for this indication is experimental and currently under investigation. The requested
service is not medically reasonable and necessary as defined by Medicare rules. The elements of the coverage
criteria are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Cystourethroscopy, with insertion of permanent adjustable transprostatic
implant; single implant (52441) and Cystourethroscopy, with insertion of permanent adjustable transprostatic
implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for
primary procedure) (52442) have not been met. Therefore, we decided that the Plan does not have to preapprove
a Prostatic Urethral Lift procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and the enrollee is a good candidate for it. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is not medically necessary, and the enrollee may have a contraindication to it.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not support the Vertiflex procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, peer-reviewed outcome studies to support the use of this device for the enrollee's condition. There is no compelling rationale or extenuating circumstance noted to support the medical necessity of this request as an exception to guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided by a participating provider on February 13, 2021.
You asked the Plan to waive the copayment for an eye exam. You say that you went for your annual eye exam. You say that this should be covered fully. 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 $35 copayment for vision care/medical eye exam. You have been asked to pay a $35 copayment for an eye exam. There is a $35 copayment for the diagnosis and treatment of diseases and injuries; therefore, the correct copayment has been applied. An eye exam falls within
the vision care/medical eye exam 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 an eye exam provided by a participating provider on February 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is required as the enrollee's needs cannot be safely met at a lower level of care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 continues to receive acute care services which have not been denied. The medical records do not indicate that he requires services that he is not currently receiving but which would be available at the LTACH facility. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 there is no documentation provided necessitating admission to an LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on September 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that your provider provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 subsequent nursing facility care (99309) provided on September 19, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided February 1, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that your dental benefit lists x-rays so you do not understand why the x-rays you received are not covered. The Plan denied your request. The Plan says this type of x-rays is not covered under your benefits.
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 intraoral - complete series of radiographic images (D0210) provided February 1, 2021.
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 you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have 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 in the Medicare rules section.
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 that you were admitted for surgical repair of a hip fracture after a fall. Medical
conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While you do require physical and occupational therapy, there is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In
conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an IRF.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428) provided on February 11, 2021.
You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you do not think you should have to pay the copayment. The Plan denied your request. The Plan says the copayment was 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for non-emergency ambulance transportation. The service at issue falls within the ambulance services benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428) provided on February 11, 2021.