Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for a transmitter, sensor, and receiver continuous glucose monitor (CGM).You asked the Plan to pre-approvea these items. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested device.The Plan must follow Medicare rules. Medicare rules say that CGMs are only when certain criteria coverage are met. We looked at the file and Medicare rules. Review of the file does not support that you have been using a BGM and performing testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve the transmitter, sensor, and receiver continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical extractions of teeth 22, 27 provided on March 13, 2020.You asked the Plan to pay forthe dental services. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says this service was not medically necessary. The records do not support the service billed.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract specifically says dental services must be received from a participating provider in order to be covered by the plan. Prior authorization may be required for dental services.Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pay forsurgical extractions of teeth 22, 27 provided on March 13, 2020.
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 the enrollee needs daily physician monitoring, and rehab therapy to improve function mobility. The Plan denied your request. The Plan says the enrollee has no medical need that requires care to be obtained in an LTACH.
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 physician reviewer found that the enrollee was admitted to the acute care hospital with ongoing chronic atypical chest pain, and a wound on her inner thigh. It has been determined that there is an infection in the right groin graft. Antibiotics are being administered. The enrollee's vital signs are normal. 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 she 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve destruction (64624) provided on January 10, 2020.
You asked the Plan to pre-approve genicular nerve destruction. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is experimental.
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 genicular nerve destruction. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials. the patient is not enrolled in a clinical trial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve destruction have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve destruction (64624) provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient surgery services provided on June 26, 2019 and July 3, 2019.
You asked the Plan to reduce the copayment for the outpatient surgery services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $350 copayment for Outpatient surgery provided in an Outpatient Hospital Facility. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgery services provided in an Outpatient Hospital Facility on June 26, 2019 and July 3, 2019. You have been asked to pay a $330.49 copayment for each date of service, which is less than the contracted $350 copayment for each date of service. The outpatient surgery services fall within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amounts 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 reduce the copayment for the outpatient surgery services provided on June 26, 2019 and July 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 including ventilator management, weaning trials, and tracheostomy care, intravenous antibiotics, surveillance laboratory studies, sacral wound care, 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-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (20610, 27370, 73580, Q9967) provided from November 8, 2018 to December 17, 2018.You asked the Plan to pay for outpatient services. You say that this was billed with valid codes.The Plan denied your request. The Plan says this claim was received untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for outpatient services was not filed until December 4, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for outpatient services (20610,27370, 73580, Q9967) provided from November 8, 2018 to December 17, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecataract surgery services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a 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 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-approvecataract surgery services to be provided 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 endodontic therapy, core buildup, including any pins when required, extraction, two retainer crowns, and pontic provided from July 22, 2019 to November 18, 2019 by an OON provider.
You asked the Plan to pay for the endodontic therapy, core buildup, extraction, two retainer crowns, and pontic. The Plan denied your request. The Plan says these services were rendered by a provider who is not in network with your health plan.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, core buildup, including any pins when required, extraction, two retainer crowns, and pontic provided from July 22, 2019 to November 18, 2019 by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 20, 2019, November 26, 2019 and December 3, 2019.
You asked the Plan to pay for the psychotherapy 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 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 psychotherapy services provided on November 20, 2019, November 26, 2019 and December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits (99214, 99215) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visits to be provided by an OON provider. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.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.Therequested 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-approveoffice visits (99214, 99215) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for diagnostic mammograms (77065) provided February 17, 2020 and March 3, 2020.You asked the Plan to waive the copayments for the mammograms. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct cost-sharing was 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 $45 copayment for Basic Imaging Services. You have been asked to pay two $45 copayments for the mammograms. The mammograms fall within the Basic Imaging 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 copayments for diagnostic mammograms (77065) provided February 17, 2020 and March 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need more physical therapy. The Plan denied your request. The Plan says you no longer need skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for skilled nursing or therapy services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on December 17, 2019.You asked the Plan to waive the copayment for an ambulance trip. You say that you feel that the services should be covered because you had no other option.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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip 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 an ambulance trip provided on December 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transportation to office visits.You asked the Plan to pre-approve the transportation services. You say that you have an orthopedic surgeon and have to see your doctor every week. You say that you are at risk of losing your limb and have no transportation or money to get back and forth to her appointments. You say that you have had 4 surgeries due to an infection.The Plan denied your request. The Plan says the services requested 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-approve transportation to office visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.You asked the Plan to pre-approve a power scooter. You say that you are unable to move around without a power operated vehicle.The Plan denied your request. The Plan says you do not meet the requirements for approval.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power scooter. Our physician reviewer found that an exam indicated that you have no difficulties with activities of daily living. You do not need help getting out of the house. You are noted to use a quad cane, scooter, wheelchair, manual and standard walker. You are noted to have problems with balance, walking, weakness in the legs. You do have a personal mobility deficit, but the documentation does not indicate that it impairs participation in mobility related activities of daily living in the home. There is no clear gait evaluation or indication why you are unable help his mobility deficit with a manual wheelchair or walker or cane. There is no trial of a PMD or home evaluation indicating the patient can safely navigate a PMD in the home.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 5, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that you were told they don't treat allergies at the hospital. You say that you were there for two hours for nothing. The Plan denied your request. The Plan says the copayment 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 $120 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The record show that you were examined, prescribed medication and advised to see an allergy specialist. 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 ER visit provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve EpiFix-wound care.You asked the Plan to pre-approve EpiFix. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that amniotic membrane derived skin substitutes are only covered for indications for the treatment of venous stasis ulcers and diabetic foot ulcers.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 EpiFix. Our reviewer says that the documentation does not support that the requested EpiFix is medically reasonable or necessary. Our physician reviewer found the enrollee has bilateral plantar fasciitis as well as postoperatively for a right silver bunionectomy with removal of hardware. The documentation does not support that the enrollee has a venous stasis ulcer and/or a diabetic foot ulcer. It appears, according to the documentation, that the enrollee is receiving the Epifix injections to alleviate plantar fasciitis pain. Therefore, this does not meet recommended guidelines, and the EpiFix injections cannot be considered 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 EpiFix have not been met.Therefore, we decided that the Plan does not have to pre-approve EpiFix-wound care.