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

We decided that the Plan does not have to pay forpodiatry services provided on July 22, 2019 to September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forpodiatry services. You say that it is the facility's responsible to obtain prior authorization.The Plan denied your request. The Plan says the member resides at an assisted living facility. The Plan says that the assisted living facility is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forpodiatry services provided on July 22, 2019 to September 23, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 10, 2020 through January 16, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 10, 2020 through January 16, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the rental of a monitoring feature/device for a positive airway pressure (PAP) device provided from June 19, 2019 to July 18, 2019 billed with code A9279.You asked the Plan to pay for the monitoring feature rental. You say that this code is correct and should be paid based on medical necessity found in the records provided.The Plan denied your request. The Plan says this code is not valid for Medicare payment purposes.The Plan must follow Medicare rules. Providers must use the correct code for items/services. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. In this case, the code A9279 is not listed as a payable code in any CMS/Medicare fee schedule. In addition, it is not clear what was delivered by the supplier to support the billing of this code. There is no delivery ticket showing that items were provided which match the description of this code on the date of service billed. Without a valid code or any evidence of what was provided to support billing this code, we find that the rules for payment of these services have not been met.Therefore, we decided that the Plan does not have to pay for the rental of a monitoring feature/device for a positive airway pressure (PAP) device provided from June 19, 2019 to July 18, 2019 billed with code A9279.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Budesonide.
You asked the Plan to pre-approve a tier exception for Budesonide. You say that you are requesting a tier exception for the drug Budesonide. The Plan denied your request. The Plan says this drug is covered under the enrollee's Medicare Part B benefit and therefore a tier exception cannot be granted.
The Plan must follow Medicare rules. The rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for a tier exception for Budesonide have not been met. Specifically, the drug at issue is being covered by the Plan under Medicare Part B. Part B Drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Budesonide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 22, 2019 to enrollee by an out of network (OON) provider.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 were rendered by an out-of-network provider without 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 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 22, 2019 to enrollee by an out of network (OON) provider.
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 do not require the intensity of services provided atan IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.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: Favorable

We decided that the Plan has to pre-approve extractions of teeth #6, 7, 8, 10, 11 for the enrollee.
You asked the Plan to pre-approve the extractions. You say that this is medically necessary. The Plan denied your request. The Plan says that the dental provider did not provide x-rays that show the dentist would need to cut the gum near the tooth, the tooth into pieces, or need to also remove some bone to be able to remove the teeth.
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 extractions 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 extractions. Our reviewer says that the requested extractions are medically reasonable and necessary. Our physician reviewer found due to the dense bone structure and fragile coronal structure of teeth #'s 6, 7, 8, 10 and 11 surgical extractions (D7210) meet the criteria for coverage as medically necessary and reasonable. 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 extractions have been met. Therefore, we decided that the Plan has to pre-approve extractions of teeth #6, 7, 8, 10, 11 for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 8, 2019 to October 7, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listedabove 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 pay for the skilled nursing services. Ourreviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not haveto pay forthe skilled nursing services provided from September 8, 2019 to October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on October 8, 2019 by an out of network (OON) provider.You asked the Plan to pay forassisted living services. You say that it is the facility's responsibility to obtained prior authorization, not the physician.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 forassisted living services provided on October 8, 2019 by an out of network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forTrain of Four Monitoring (95999) provided on August 16, 2019.You asked the Plan to pay forthe Train of FourMonitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says Train of Four is considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoring.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 95999 is not supported in the record. Specifically, Train of Four Monitoring is considered integral to the primary procedure and therefore is part of a bundled payment. Based on this information, we decided that Medicare rules for coverage of the Train of Four Monitoring have not been met.Therefore, we decided that the Plan does not have to pay forTrain of Four Monitoring (95999) provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology visits for Eylea injections to be provided while out of area (OOA).You asked the Plan to pre-approve the OOA eye injections. You say that you need to have these injections every six weeks and you will be in Florida for 12 weeks. Your doctor states that is too long and you do not wish to risk your vision.The Plan denied your request. The Plan says coverage of OOA care is limited to emergency and urgently needed care. Urgently needed means treatment of an unforeseen medical complication of a known condition. Scheduled treatments do not meet this criterion.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  The requested services are not considered urgently needed OOA care because the need for these treatments is/was known prior to leaving the service area.Therefore, we decided that the Plan does not have to pre-approve ophthalmology visits for Eylea injections to be provided while out of area (OOA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stem cell transplant evaluation.You asked the Plan to pre-approve the evaluation. You say that you are due for another round of shots for a health issue, and you are willing to pay out of pocket for whatever is not covered.The Plan denied your request. The Plan says there are multiple standard therapies for osteoarthritis.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 evaluation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found platelet rich plasma/stem cell knee injections in this case are not medically reasonable and necessary. These injections do not meet the definition of medically reasonable and necessary as defined by the Social Security Act, Section 1862(a)1(A).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 evaluation have not been met.Therefore, we decided that the Plan does not have to pre-approve a stem cell transplant evaluation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network transplant services provided to the enrollee on November 11, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 service 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 out of network transplant services provided to the enrollee on November 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on August 27, 2019.You asked the Plan topay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed and there is a more appropriate code for these services. 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 forthe services rendered to the enrollee on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided by provider on November 22, 2019.You asked the Plan to pay for home infusion services. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these procedure codes are not valid for Medicare purposes and are not payable.The Plan must follow Medicare rules. Medicare rules say that procedure codes 99601 and 99602 are not valid for Medicare purposes and are not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion services have not been met.Therefore, we decided that the Plan does not have to pay for home infusion services provided by provider on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 12, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that prior authorization was not obtained because the provider presumed the he participated with the Plan. The Plan denied your request. The Plan says no prior authorization was 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 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 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 forthe medical services provided to the enrollee onSeptember 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the nursing home is responsible for obtaining prior authorization.The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate network providers were found.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 servicesat 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 OON services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee on September 24, 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 services (CPT 74019) provided on October 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed on a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim. These services were previously paid by the Plan for the same provider on the same date of service. 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 the services (CPT 74019) provided on October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for rib fracture treatment (21812) provided on October 3, 2019.
You asked the Plan to pay for the rib fracture treatment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted supports 1 unit of this service was performed.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the rib fracture treatment have not been met. Specifically, the record indicate that this service was previously processed and paid. The records submitted do not indicate that an additional service was rendered. Therefore, we decided that the Plan does not have to pay for rib fracture treatment (21812) provided on October 3, 2019.