Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 physical therapy visits to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on June 5, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on June 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on January 21, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that on the date of service you were discharged from the hospital following knee surgery. You say that upon arriving home you began to feel dizzy and you lost consciousness. Your daughter called 911 and the emergency service responders arrived and began checking you over. You say that you regained consciousness and eventually became stable. You stated that there was no need to go to the emergency room or the hospital. You say that by not being transported to the hospital you saved the additional expenses that would have come with it. You say that the cost of the ambulance services are a financial burden and you asked the Plan to reconsider covering the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 31, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain
(70551).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied
your request. The Plan says rules for coverage were not met.
The Plan must follow Medicare rules. Medicare rules say that 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 the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the
MRI is not medically necessary. Our physician reviewer found the enrollee is being evaluated for memory loss
and an MRI of the brain was requested. There has not been a clinical diagnosis of dementia. The provided
records do not support that the MRI is 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 the MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve Magnetic Resonance Imaging (MRI) of the brain (70551).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided the home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. The enrollee does not have documentation of skilled services being received or 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 home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visits provided on August 19, 2019, August 27, 2019
and October 1, 2019.
You asked the Plan to pay for the home visits. The Plan denied your request. The Plan says the enrollee must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from 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 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 home visits provided on August 19, 2019, August 27, 2019 and
October 1, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on November 1, 2019.
You asked the Plan to pay for nursing facility care. You say that this service was medically necessary. The Plan
denied your request. The Plan says payment for this service is the responsibility of Original Medicare.
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 nursing facility care (99309) provided on November 1, 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly
moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive,
longer duration of therapy will allow for measurable gains to be attained within a reasonable period.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lumbar/sacral interlaminar epidural injection.You asked the Plan to pre-approvethe lumbar/sacral interlaminar epidural injection. You say that the procedure is medically necessary and the records provided support this need.The Plan denied your request. The Plan says the requested procedure is considered a benefit exclusion because it isnot medicallynecessary.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 lumbar/sacral interlaminar epidural injection. Our reviewer says that therequested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records note that the enrollee received a series of 3 epidural injections, with the last lumbar epidural injection having been providedon May 9, 2020. It has been less than 6 months since the enrollee's series of 3 injections. This means that the criteria for coverage of a repeat epidural injection has not been met 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 lumbar/sacral interlaminar epidural injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea lumbar/sacral interlaminar epidural injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin B12 injection provided on January 7, 2020.You asked the Plan to pay for the injection. 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 pay for the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided the requested Vitamin B-12 injection was not medically reasonable and necessary as there was no documentation of Vitamin B-12 deficiency.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 injection have not been met.Therefore, we decided that the Plan does not have to pay for the vitamin B12 injection provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildups, including any pins when required (D2950) for tooth #'s 21 and 30 and a crown (D2750) for tooth #30.You asked the Plan to pre-approvethe core buildups and crown. The Plan denied your request. The Plan says core buildup is not a covered benefit. The Plan also says that the x-rays do not show that the enrollee has a cavity under the crown they already have.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 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 crown. Our reviewer says that the crown for tooth #30 is not medically necessary. Our physician reviewer found there is no apparent issue with tooth #30. It has an existing crown that is not clearly defective. There is no clinical information indicating a defect or decay of any kind on tooth #30. Our reviewer also found that without support for the contention that the crown or tooth around it was defective in some way, there can be no finding of medical necessity for a new crown on #30.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99281) provided February 10, 2020.
You asked the Plan to waive the copayment for the Emergency Room Visit. You say that the copayment should be waived because you left the ER. The Plan denied your request. The Plan says since you were admitted to the ER, 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 $90 copayment for Emergency Care. You have been asked to pay a $70.36 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care benefit category. This Medicare allowable amount is less than the $90 copayment stated in the plan contract. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99281) provided February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the Head and Neck (70468) provided March 4, 2020.
You asked the Plan to waive the copayment for the CT scan. 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 $225 copayment for Advanced Imaging Services. You have been asked to pay the allowable amount of $139.87 for the CT scan. The CT scan falls within the Advanced Imaging Services benefit category. The allowable amount is less than the $225 copayment stated in the plan contract. 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 Computed Tomography (CT) of the Head and Neck (70468) provided March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for continued SNF care. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued coverage of skilled nursing care at a SNF. The Plan says that there is no documentation to support the medical necessity for a skilled level of care. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medication and insulin. The enrollee had stable vital signs. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question, the enrollee was at a moderate to maximal assist level with functional mobility, including gait to 50 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee required a pureed diet and nectar thickened liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 February 19, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 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 February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from February 6, 2019 to March 26, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from February 6, 2019 to March 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was 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 the drug testing services provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forframes and lenses purchased March 10, 2020 from an out of network provider.You asked the Plan to pay forthe vision services. You say that you never received changedto out of network. You don't use the internet so you call or wait on the mail.The Plan denied your request. The Plan says vision services provided by an out of network provider is not covered by the plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when enrollee's must receive their vision services from an in-network provider..We looked at the file and the Plan's rules. enrollee's must receive their medical services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forframes and lenses purchased March 10, 2020 from an out of network provider.