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

We decided that the Plan does not have to pay for lab services provided on March 12, 2020 by an out of network (OON) provider.You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 lab services provided on March 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with provided on January 27, 2020.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to the enrollee during an inpatient stay and should be covered The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services (99190) have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topreapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information wedecided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic services provided on February 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient clinic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 outpatient clinic services provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the physical therapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the neurostimulator implantation provided on November 8, 2019.
You asked the Plan to waive the coinsurance for the neurostimulator implantation. You say that the temporary trial was only 60% successful. You say that the amount is excessive. The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for each in-network, Medicare-covered outpatient hospital facility visit. You have been asked to pay $1,736.54, which is 20% of the allowed amount for the neurostimulator implantation. The allowed amount is $8,682.74 (20% x $8,682.74 = $1,736.54). The neurostimulator implantation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the procedure was performed.
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 coinsurance for the neurostimulator implantation provided on November 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient psychotherapy services.
You asked the Plan to pre-approve outpatient psychotherapy services. You say that the requested outpatient
psychotherapy services are medically necessary. The Plan denied your request. The Plan says the requested
outpatient psychotherapy services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve outpatient psychotherapy services. Our
reviewer says that the requested outpatient psychotherapy services are not medically necessary. Our physician
reviewer found this enrollee is being treated for Generalized Anxiety Disorder. Based on review of the records
provided, it is noted that this enrollee had previously been approved for 8 units of 90837 psychotherapies, 60
minutes visits between January 27, 2020 and April 26, 2020. Based on review of the records provided this
enrollee does not require additional treatment sessions as utilizing the CMS criteria for coverage she did not
utilize the previously approved visits as noted above. Clearly the documentation shows the poor utilization of
the approved treatments shows the members symptoms/acuity to be considered mild in nature and therefore not
reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of outpatient psychotherapy services have not been met. Therefore, we decided
that the Plan does not have to pre-approve outpatient psychotherapy services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe physician services provided from December 14, 2019 to December 15, 2019.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.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 is denying payment for CPT code 99231; however, the Plan has not provided any claims showing this code was denied for payment. The provider is appealing the denial of payment for CPT codes 99221 and 99232. The Plan has not provided any information in regards to their reason for denial of the codes in dispute based on Medicare guidelines.Therefore, we decided that the Plan has to pay forthe physician services provided from December 14, 2019 to December 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery powered nebulizer.
You asked the Plan to pre-approve a battery powered nebulizer. You say that lately there has been power
shortages in your area and you are unable to use your nebulizer then. The Plan denied your request. The Plan
says the requested nebulizer machine is considered a backup to your previously approved nebulizer machine
and therefore not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have an electric nebulizer. An electric nebulizer serves the same purpose as a battery
powered nebulizer. Backup medical equipment is defined as an identical or similar device used for
precautionary reasons when the primary equipment malfunctions. Medicare does not pay separately or make an
additional payment for backup equipment. Therefore, we decided that the Plan does not have to pre-approve a
battery powered nebulizer.
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. The Plan denied your request. The Plan says the enrollee is currently too weak to participate in acute rehab.
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 the enrollee presented to the acute hospital with swelling of the left arm and frequent falls after recent left shoulder rotator cuff surgery. She was treated in the hospital for acute renal failure and weakness. Evidence of lumbar spinal stenosis was found on spine imaging. She is weak and deconditioned and is working with physical and occupational therapy. She is walking with a cane with contact guard assistance and is minimum assist for transfers and activities of daily living. She is medically stable. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee does not require an intensive inpatient rehabilitation therapy 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 add tooth to existing partial denture (D5650) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 31, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting that the plan issue payment in full for the services provided. The Plan denied your request. The Plan says you exceeded your 2019 dental benefit of $1000 per calendar year.
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. You exhausted your $1,000 benefit allowance. Your EOC states, you pay amount over $1,000 for dental services. Therefore, we decided that the Plan does not have to pay for add tooth to existing partial denture (D5650) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued occupational therapy.
You asked the Plan to pre-approve continued occupational therapy. You say that these services are medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has not met her goals.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued occupational therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment or that the services can be safely and effectively performed only by or under the supervision of a therapist. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued occupational therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requested drug rehabilitation/detoxification program. You asked the Plan to pre-approvethe drug rehabilitation/detoxification program.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergencyor urgent care or if the care cannot be provided with an in-network provider.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvethe requesteddrug rehabilitation/detoxification program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided on November 13, 2019.You asked the Plan to pay forthe services. You say that the services were medically necessary.The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for blood smear interpretation services provided on March 9,
2020.
You asked the Plan to pay for the provided services. You say that the procedure was rendered in the
appropriate place of service. The Plan denied your request. The Plan says that the only payment made for the
professional component of the code is for hospital inpatient.
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 85060 is blood smear, peripheral, interpretation by
physician with written report. The professional component of clinical laboratory codes for which separate
payment may be made only if the physician interprets an abnormal smear for hospital inpatient. No payment is
recognized for CPT codes 85060 furnished to hospital outpatients or non-hospital patients. The physician
interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. Based
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that
the Plan does not have to pay for blood smear interpretation services provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records indicate that there are no significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a skilled nursing facility. In this case, the enrolleeis mostly MAXassist for functional transfers and activities of daily living. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may be more appropriate.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 an 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 physician's services provided on February 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided from December 6, 2019 to December 7, 2019.
You asked the Plan to pay for self-administered drugs. You say that this should be covered. The Plan denied your request. The Plan says coverage of these medications is the responsibility of the enrollee's prescription drug 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 for self-administered drugs (A9270) provided from December 6, 2019 to December 7, 2019.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.