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

We decided that the Plan does not have to pre-approve additional routine transportation trips.You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips to get to dialysis.The Plan denied your request. The Plan says that you are only covered for twelve trips.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twelve (12) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to approve routine transportation of the benefit maximum of twelve (12) trips for routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on June 2, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 61619 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 61619 is secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle).We find that CPT code 61619 is not supported in the medical record. Specifically, the operative report does not contain documentation that secondary repair of the dura for a cerebrospinal fluid leak was performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the services rendered on June 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal surgery (226333, 22214, 22840, 20936, and 69990) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON spinal surgery. You say that this provider could correct your issues.The Plan denied your request. The Plan says there are in-network providers available for these services.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. These services are available within the Plan's network.Therefore, we decided that the Plan does not have to pre-approvethe spinal surgery (226333, 22214, 22840, 20936, and 69990) to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve routine (non-ambulance) transportation to medical appointments.You asked the Planto pre-approve the routine transportation. You say that you need to get to appointments with pain management and primary doctors in order to keep your post-surgery recovery moving forward.The Plandenied your request. The PlansaysMedicare does not cover non-ambulance transportation. Your plan does not include any supplemental benefit which would cover this service.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the routine transportation have not been met.Therefore, we decided that the Plandoes not haveto pre-approveroutine (non-ambulance) transportation to medical appointments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveContour Next test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips.You say that the enrollee wants to continue to use the Contour Next brand of test strip.The Plandenied your request. The Plan says no records or certificate of medical necessity was provided to show the reason for using the non-preferred brand.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules.There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips. have not been met.Therefore, we decided that the Plan does not have to pre-approveContour Next test strips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for your routine transportation.You asked the Plan to pre-approveadditional miles. You say that you need transportation to your procedure.The Plan denied your request. The Plan says your benefit only allows fifty miles.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Transportation for over 50 miles wasrequested. We looked at your request, the records in the case file, and the rules. Your plan only covers trips for up to 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional mileage for your routine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided thatthe Plan does not have to pay forthe drug testing rendered on July 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from September 27, 2019 through September 28, 2019.You asked the Plan to pay forthese drugs. The Plan denied your request. The Plan says that this is not covered under your plan.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 pay forthe self-administered drugs provided from September 27, 2019 through September 28, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99213, 90836) provided January 29 to September 12, 2019. You asked the Plan to pay forthe psychotherapy services. You say that you were told the services would be covered.The Plan denied your request. The Plan says providers who opt-out of Medicare are not eligible for payment.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physi the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services (99213, 90836) provided January 29 to September 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 this is not medically necessary.
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 long term acute care hospitals (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 respiratory support with ventilator management and
tracheostomy care, intravenous antibiotics, surveillance laboratory studies, tube feedings, 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 admission to a long term acute care hospital (LTACH) 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 August 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician visit. You say that you had an authorization for this service, so the Plan should pay this claim in the full allowed amount. 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 pay for the medical services provided on August 25, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to waive the copayment for the office visit and x-ray. You say that these are from an injury and should be covered by the settlement. The Plan denied your request. The Plan says the copayments 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 $50 for each Medicare-covered visit with an in-network specialist and $35 per day, per in-network provider, for Medicare-covered x-ray services. You have been asked to pay a total of $75.34 for the office visit and x-ray.
Service
Allowed Amount
Standard Copayment
Member Liability
Office Visit
$43.61
$50
$43.61
X-Ray
$31.73
$35
$31.73
TOTAL:
$75.34
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 office visit and x-ray provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 20, 2019.You asked the Planto pay for the physician's services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network providerwith the Plan. The Plan did not pre-approve the servicesat 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 physician's services providedon September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve smoke detectors.You asked the Plan to pre-approve smoke detectors. You say that you are fully disabled and live alone.The Plan denied your request. The Plan says a smoke detector does not serve a primary medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve smoke detectors.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the comprehensive metabolic panel rendered to you on October 18, 2019.You asked the Plan to pay for these services. You say that you needed the testing.The Plan denied your request. The Plan says that the services are not covered.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. The Plan states that the comprehensive metabolic panel is covered only once every six months; however, the Plan has not provided any Medicare rules or documentation to support this denial reason. It is noted that an Advanced Beneficiary Notice (ABN) was given, but this alone is not sufficient to support that the services are not covered. There is no documentation to support that this testing is not covered by Medicare. Therefore, we decided that the Plan has to pay for the comprehensive metabolic panel rendered to you on October 18, 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: 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 cannot do anything without assistance.The Plan denied your request. The Plan says care in an IRF exceeds your medical needs.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 physician reviewer found that you are not medically stable after a stroke with mild deficits. Functionally, you require contact guard to minimal assist. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with an interdisciplinary approach to rehabilitation care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on October 14, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthese non-urgent services were not authorized.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 Plandoes not haveto pay forlab services provided to the enrollee on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on May 16, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered on May 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided on October 21, 2018.You asked the Plan to pay for the home health care services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules saythat 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 servicesat 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 home health care services provided on October 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on July 1,
2019.
You asked the Plan to pay for CPT 95999. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is
"Unlisted neurological or neuromuscular diagnostic procedure".
We find that CPT code 95999 is not supported in the medical record. Specifically, train of four testing is not an
unlisted procedure. There is a more appropriate CPT code for train of four testing. Additionally, train of four
testing is a bundled procedure and is not separately payable. Based on this information, we decided that
Medicare rules for coverage of CPT 95999 have not been met. Therefore, we decided that the Plan does not
have to pay for the train of four testing (CPT 95999) provided on July 1, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fire extinguishers.You asked the Plan to pre-approve fire extinguishers. You say that you are a smoker and wants them for safety purposes.The Plan denied your request. The Plan says a fire extinguisher does not serve a primarily medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve fire extinguishers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device and associated accessories to be provided to the enrollee by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the necessary services may be obtained in-network.
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 at issue in this appeal. As a courtesy, the plan has agreed to cover one-month rental for the items at issue from the requested provider. We found no exception that would require the Plan to pre-approve additional OON services. Therefore, we decided that the Plan does not have to pre-approve a CPAP device and associated accessories to be provided to the enrollee by an out of network (OON) provider.