Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric services for the enrollee.You asked the Plan to pre-approvecontinued services. You say that the enrollee has failed outpatient psychiatric treatment.The Plan denied your request. The Plan says the enrollee does not have acute symptoms that require 24-hour care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 services. Our physician reviewer found that active treatment was not taking place. It does not appear that the services were reasonably expected or medically necessary to improve the enrollee's condition, or for the purpose of diagnosis. The enrollee does not meet the criteria for treatment February 26, 2020, forward, andcould be treated in a lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 9, 2018.You asked the Plan to pay forthe services. You say that you were never told you would have to pay this.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care fromnetwork 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. 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 forthe medical services provided to the enrollee by an out-of-network provider on October 9, 2018
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 this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs are met with his current home health care.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 the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical and occupational therapy but the patient does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5211).
You asked the Plan to pay for the maxillary partial denture. You say that you lost your previous dentures. You also say that you should be able to use the $3,000 allowance for this service. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, maxillary dentures, one of (D5110, D5130, D5211, D5213) are limited to once per 60 months. The record shows that you received a maxillary partial denture (D5213) on March 16, 2019 and your maxillary dentures benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5211).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214), and an assessment for prescription eye wear using a range of lens powers (92015) provided on June 4, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit, and an assessment for prescription eye wear. You say that the patient is covered under a Medicare Advantage Plan and services were medically necessary.The Plan denied your request. The Plan says the clinical documentation supports that the services were routine and lacked any medical emergency or urgency. The records donot support attempts were made for prior authorization of services by the member or non-network provider. In-network eye care services were readily available to the member at the time of service.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 foran office visit (99214), and an assessment for prescription eye wear using a range of lens powers (92015) provided on June 4, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are in pain due to having plantar fasciitis. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound filler (A6010) and gauze (A6219) provided on September 30, 2019.
You asked the Plan to pay for the wound filler and gauze. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes were billed in a Skilled Nursing Facility place of service meaning Medicare rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that this claim was billed with POS 31 indicating that the wound filler and gauze were used in an SNF or hospital. Therefore, we decided that the Plan does not have to pay for wound filler (A6010) and gauze (A6219) provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says there is no clinical advantage of the LTACH over the current acute hospital setting.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 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 oxygen supplementation, surveillance laboratory studies, specialty consultation, nutrition assessment, and therapy services. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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-approvelong term acute care hospital (LTACH) services for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo core buildups, including any pins when required (code D2950).You asked the Plan to pre-approvethe core buildups. You say that tooth #'s 13 and 14 are fractured and you are recommending this treatment to save the enrollee's teeth.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers adental 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 pre-approvetwo core buildups, including any pins when required (code D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for enrollee.You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires aggressive vent weaning, rehab therapy, and physician monitoring.The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting.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 is currently undergoing treatment at an acute care hospital (ACH) for acute-on-chronic respiratory failure. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee then developed gram negative sepsis. The enrollee appears to have made little to no progress with ventilator weaning and remains hemodynamically labile. It is unclear that weaning is achievable or advisable at the present time. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoncology services at a tertiary facility.You asked the Plan to pre-approvethe oncology services at a tertiary facility. You say that you are being treated for cancer and are supposed to start your treatment on March 2, 2020. You say that you had been approved for treatment at the tertiary facility for 5 months and that the Plan is suddenly stopping your treatment.The Plan denied your request. The Plan says it is not medically necessary for the enrollee to receive treatment at the in-network tertiary level of care facility. The Plan says that the enrollee ca n be treated byan in-network non-tertiary provider.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 the oncology services at a tertiary facility. Our reviewer says that a tertiary level of care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a fine needle aspirate parotid mass, suggestive of a neoplasm. Our physician reviewer found that there is no medical necessity for a tertiary level of care for treatment of the enrollee's condition and that the request is for patient preference only.Our physician reviewer found that an in-network non-tertiary level of care provider can adequately provide the treatment the enrollee requires.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the oncology services at a tertiary facility have not been met.Therefore, we decided that the Plan does not have to pre-approveoncology services at a tertiary facility.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips, beyond the allotted 50 a year.You asked the Plan to pre-approvethe additional routine transportation trips. You say that the enrollee is currently under your care for the diagnosis of breast cancer. You say that the enrollee is undergoing treatment and will need to continue treatment for more visits.The Plan denied your request. The Plan says the transportation services being requested are beyond the number of trips that are covered for the enrollee's 2020 calendar year.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 50 one-way non-emergency transportation trips.We looked at your request, the records in the case file, and the rules. The records show that the enrollee has used 44 routine transportation trips. This means that the enrollee has coverage for 6 routine transportation trips remaining before the routine transportation benefit is exhausted. Any more than these remaining routine transportation trips, exceed the benefit allowance for this type of service.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips, beyond the allotted 50 a year.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiography provided on October 14, 2019.You asked the Plan to waive the copayment forthe echocardiography. You say that you didn't need the stress test. You say that you shouldn't have to pay the copayment.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 $200 copayment for Medicare-covered diagnostic test and procedures at an outpatient hospital setting.You have been asked to pay a $200 copayment for the echocardiography. The echocardiography falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The records show thatthe echocardiography 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 copayment forthe echocardiography provided on October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the eylea injections to be provided by an OON provider.You asked the Plan to pre-approve the eylea injections. You say that you are overdue for a treatment at this provider's office.The Plan denied your request. The Plan says the provider you have requested this service to be rendered by is OON.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-approve the eylea injections to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance forthe eye muscle surgery provided on September 3, 2019.You asked the Plan to reduce the coinsurance forthe eye muscle surgery. You say that this should be billed as an ambulatory surgical center visit with a $375 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 20% coinsurance for each Medicare-covered visit at an outpatient hospital. You have been asked to pay $635.50 which is 20% of the allowed amount for the eye muscle surgery. The allowed amount is $3,177.53. ($3,177.53 x20% = $635.50). The eye muscle surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the place of service was an outpatient hospital.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 reducethe coinsurance forthe eye muscle surgery provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213), a duplex scan (93925, 93971) provided on May 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit, and a duplex scan. You say that the services were based on medical necessity. The patient was referred by another specialist for bilateral lower extremity for a non-healing ulcer. The patient needed to be evaluated by vascular surgery. The primary care physician was not involved in the episode of care. The Plan denied your request. The Plan says the facility, a non-contracted provider, is appealing the denial of diagnostic testing rendered on May 10, 2019. The non-contracted provider states that the physician, also a non-contracted provider, referred the enrollee. There is no valid referral for this service.
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 an office visit (99213), a duplex scan (93925, 93971) provided on May 10, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast tomosynthesis (77061) provided on October 22, 2019.You asked the Plan to pay for the breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per the 2019 National Physician Fee Schedule, CPT code 77061 has a status code of I.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 77061 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, CPT code 77061 has a status code of I. This means that 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for the breast tomosynthesis (77061) provided on October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on November 19, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you hadno control over the transfer.The Plan denied your request. The Plan says that they are unable to waive any applicable cost sharing.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for a Medicare-covered one-way ambulance trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way ambulance trip 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 forthe ambulance transport provided on November 19, 2019