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

We decided that the Plan does not have to pre-approve SNF admission and services for enrollee.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee has a high level of function.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 services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a modified independent to standby assist level with functional mobility. She could groom and toilet independently. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a flu shot provided on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a flu shot. You say that you were told at the pharmacy that the shot was covered. You say that it wasn't until after the shot that you found out that your medical and pharmacy coverage were different. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 a flu shot provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).You asked the Plan to pre-approve bone marrow aspiration (20939). You say that the requested bone marrow aspiration is medically necessary.The Plan denied your request. The Plan says the requested bone marrow aspiration is 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 casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee is with progressive neurological symptoms and exam findings due to disc disease and stenosis at L4-5, L5-S1. The Plan approved the requested L4-L5 and L5-S1 transforaminal lumbar interbody fusion and associated inpatient hospital admission. Bone marrow aspirate remains experimental in cases of lumbar fusion. More research is needed. The requested bone marrow aspiration is not medically reasonable or necessary 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 bone marrow aspiration (20939) have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939)
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service on September 16, 2019.
You asked the Plan to pay for the ground mileage and ambulance service. You say that this is a payable service under Medicare Guidelines because these services were not yet hospice related. You also say that the transport was medically necessary due to the advanced condition of the enrollee needing to enter into hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and ambulance service on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a cardiologist outside of your PCP's referral circle.
You asked the Plan to pre-approve these services. You say that the physician felt that another physician would be a better choice to complete your surgery. The Plan denied your request. The Plan says the services are available from providers within the PCP referral circle.
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 providers outside of the PCP referral circle only in cases involving emergencies, out of area urgent care and care that cannot be provided by providers within the PCP referral circle. The requested provider in this case is not a provider within your PCP's referral circle. The Plan has providers within your PCP referral circle available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to a cardiologist outside of your PCP's referral circle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup and the porcelain/ceramic crown.
You asked the Plan to pre-approve the core buildup and the porcelain/ceramic crown. You say that you want to use your dental benefit. You say that you had x-rays that confirm you do not have an infection. The Plan denied your request. The Plan says the criteria for coverage has not been met.
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 Plan covers the core buildup and the porcelain/ceramic crown when the services are medically necessary and reasonable. 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 core buildup and the porcelain/ceramic crown. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that prior to the restorative treatment, the assurance that there is not an active infection is necessary since this may affect the prognosis of the restorative treatment. Our reviewer found the assurance that there is no infection is in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the core buildup and the porcelain/ceramic crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the core buildup and the porcelain/ceramic crown.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on August 9, 2019.You asked the Plan to pay forthe laboratory services. You say that the claim should be reprocessed at the in network rate. You also say that this provider is the only one that performs this testing.The Plan denied your request. The Plan says the enrollee was enrolled in hospice at the time the services were rendered. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage ofPart B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and bone replacement graft for ridge preservation provided on June 24, 2019.You asked the Plan to pay for the extraction and bone replacement graft. You say that you extracted tooth #19 due to a vertical root fracture. You also say that you provided a bone graft to preserve the ridge.The Plan denied your request. The Plan says the enrollee's Plan does not provide a benefit for these procedures.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 forthe extraction and bone replacement graft for ridge preservation provided on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) Physician or acute rehab nursing care in an IRF. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program with multidisciplinary approach. IRF admission is not 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRFcare. You say that you have a rare form of lymphedema that is rapidly spreading.The Plan denied your request. The Plan says you do not  have an active medical condition which requires physician supervision three times weekly, or an interdisciplinary approach to 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 you ae hemodynamically stable. There are no signs or symptoms of pending sepsis, fever, or neurological change. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Youare at a moderate to maximum assist level for functional transfers and activities of daily living. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Divigel for the enrollee.You asked the Plan to pre-approve Divigel. You say that the enrollee has been using this medication with excellent success for years.The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Divigel for the enrollee.Benefits for Divige lmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on July 18, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you did not want to go to the emergency room and you should not be responsible for this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during the emergency room visit.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 forthe emergency room visit provided on July 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for out-of-network services. You say that this service was not authorized because it was intended to be a workers compensation follow up. The Plan denied your request. The Plan says out of network services require authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 19, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine (72131), magnetic resonance imaging (MRI) of the lumbar spine (72148), and an MRI of the cervical spine (72141).You asked the Plan to pre-approvea CT of the lumbar spine, an MRI of the lumbar spine, and an MRI of the cervical spine. You say that this is medically necessary.The Plan denied your request. The Plan says the same studies have been previously done.The Plan must follow Medicare rules. Medicare rules say that CT scans and MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve a CT of the lumbar spine, an MRI of the lumbar spine, and an MRI of the cervical spine. Our reviewer says that the requested imaging services are not medically necessary. Our physician reviewer found the enrollee has recently had a spinal CT. There are no new neurologic symptoms to repeat the test or indications for MRIs.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 CT of the lumbar spine, an MRI of the lumbar spine, and an MRI of the cervical spine have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the lumbar spine (72131), magnetic resonance imaging (MRI) of the lumbar spine (72148), and an MRI of the cervical spine (72141)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on October 8, 2019.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you did have breast cancer and you should have a yearly mammogram at no charge. The Plan denied your request. The Plan says the deductible amount was removed and will only apply the $10 copayment.
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 $10 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $10 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a history of breast cancer which makes the mammogram diagnostic in nature.
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 diagnostic mammogram provided on October 8, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on June 20, 2019.
You asked the Plan to pay for the ambulance service and ground mileage. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on June 5, 2019.You asked the Plan to pay for the panoramic x-ray. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 forthe panoramic x-ray provided on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 25, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the member received this service during inpatient hospitalization. The payment for this service is included in the DRG-payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 25, 2019.