Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine you received on September 13, 2019.
You asked the Plan to pay for the shingles vaccine. You say that the immunization helps ensure that costly treatment of serious complications will not be required. The Plan denied your request. The Plan says the service is not a covered benefit under the medical benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine you received on September 13, 2019.
Benefits for the shingles vaccine may 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you do not directly see the enrollee and it would be inappropriate to refuse the enrollee's specimen for testing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 November 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 8, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 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 November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional trips for routine transportation.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not a covered benefit.
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 30 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve 30 additional trips for routine transportation.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee had a rod placement for a right femur fracture on March 7, 2020. As of March 11, 2020 all labs are normal and her chronic medical conditions are stable. Her kidney injury has resolved. She has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on September 13, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 96440 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 96440 is chemotherapy administration into pleural cavity, requiring and including thoracentesis. We find that CPT code 96440 is not supported in the medical record. Specifically, there is no documentation of chemotherapy administration into the pleural cavity. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs close respiratory monitoring. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a hemorrhagic stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee appears to be tolerating ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were unaware that you were not in-network with the patient's specific plan. 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 physician services provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that you had no knowledge the enrollee's plan changed. The Plan denied your request. The Plan says authorization for out-of-network services was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on August 26, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound guided needle placement (76942) performed November 6, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $50 copayment for Basic Imaging. You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the Basic Imaging 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 ultrasound guided needle placement (76942) performed November 6, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for psychotherapy services (90832) provided on October 9, 2019.
You asked the Plan to waive the coinsurance for the psychotherapy services. You say that the coinsurance 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 35% coinsurance for out-of-network outpatient mental health services. You have been asked to pay a 35% coinsurance for the psychotherapy services. The psychotherapy services fall within the out-of-network outpatient mental health 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 coinsurance for psychotherapy services (90832) provided on October 9, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 12, 2019
to September 6, 2019.
You asked the Plan to pay for the skilled nursing services. You say that are requesting reconsideration for
services paid for by the facility. The Plan denied your request. The Plan says the Medicare hospice
benefits covers attending physician services and all care unrelated to the terminal illness until the first day of
the month following the month in which hospice was revoked or discharged.
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. The record
shows proof of hospice election beginning on August 18, 2019. Therefore, we decided that the Plan does not
have to pay for the skilled nursing services provided from August 12, 2019 to September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on June 26, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the healthplan and listed in the Provider Directory.
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 office visit services provided to the enrollee on June 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reline complete maxillary denture (D5750) and reline complete mandibular denture (D5751) provided on June 4, 2019.
You asked the Plan to pay for the dental services. You say that you were given a different price and paid the full amount. The Plan denied your request. The Plan says the services are not a covered benefit under the 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 among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for reline complete maxillary denture (D5750) and reline complete mandibular denture (D5751) provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arterial duplex scan.
You asked the Plan to pre-approve the study. The Plan denied your request. The Plan says this 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 case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the study. Our reviewer says that the requested duplex scan is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is documentation that the enrollee denies symptoms consistent with claudication. There is no documentation of an abnormal pulse examination. There is no documentation of an abnormal ABI study. Medical necessity would require that the enrollee's symptoms be consistent with claudication and absence of documentation stating the opposite. Additionally, there would be documentation of an abnormal pulse examination, or abnormal ABI study, and documentation that symptoms are significant enough to be either limb threatening or functionally limiting to the point that intervention would be considered. As none of these items are documented in the medical record, medical necessity is not supported. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve an arterial duplex scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is a network lock-in issue, as medically necessary care is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/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 an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 23, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of
the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
services provided to the enrollee on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation for a total of 57.8 miles.
You asked the Plan to pre-approve these services. You say that you need to see this provider. The Plan denied your request. The Plan says the request exceeds the mileage limit.
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 routine transportation for 24 one-way trips and each trip must not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a one-way trip of 57.8 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation for a total of 57.8 miles.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says your condition was no longer improving.
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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing rendered to the enrollee on September 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. The rules say that the patient's medical record must include an appropriate testing frequency. We looked at the file and Medicare rules. The documentation does not support the frequency of the testing performed. The file shows that greater than 18 tests were performed for this enrollee in one year. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing rendered to the enrollee on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 3, 2019.