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

We decided that the Plan does not have to pre-approve the SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you were discharged from the hospital too early. You also say that SNF admission is medically necessary.The Plan denied your request. The Plan says that SNF admission is not medically necessary.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 admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvethe SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins provided on September 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a duplex scan of extremity veins. You say that the facility piggybacks off any authorization obtained by the nursing home because out billing POS is the nursing facility. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a duplex scan of extremity veins provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation visit with "the doctor".You asked the Plan to pre-approve the consultation visit. Yousay that this physician has had successful results using KTP laser surgery on squamous cell carcinoma in situ.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or ifthe care cannot be provided with an in-network provider, which requires prior authorization from the planMedicare 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a consultation visit with "the doctor".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala Auto-Injector.
You asked the Plan to pre-approve Nucala Auto-Injector. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Nucala Auto-Injector is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucala Auto-Injector.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was seen by her primary care physician (PCP) on 1/30/20 for anxiety, dizziness, andlower extremity weakness. On 2/11/20 she returned to her PCP with complaints of frequent falling and unsteadiness on her feet. The enrollee has a history of atrial fibrillation, high blood pressure, vitamin D deficiency, brain tumor with epilepsy, and lower leg swelling. Her prior level of function was ambulating with a rolling walker and was independent with activities of daily living. She lives with family in a one story home with 2 steps to enter. Her current level of function is supervision with bed mobility, minimal assist with transfers, minimal assist with ambulating with a rolling walker, and supervision/minimal assist with dressing. Based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While she may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided on September 10, 2019.You asked the Plan to pay for cataract surgery. You say that the procedure is not related to hospice. You say that the claim should be reprocessed.The Plan denied your request. The Plan says Original Medicare is responsible for payment.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 cataract surgery provided on September 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for 4 units of mileage for ambulance services provided on June 8, 2019.
You asked the Plan to pay for 4 mileage units. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claimed mileage units should not have been rounded up.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 4 units of CPT code A0425 are not supported in the record. The record supports 3.4 units of CPT code A0425. This mileage should have been reported to the nearest tenth of a mile. Based on this information, we decided that Medicare rules for coverage of 4 mileage units have not been met. Therefore, we decided that the Plan does not have to pay for 4 units of mileage for ambulance services provided on June 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bed purchased on June 3, 2019.
You asked the Plan to reimburse you for the bed. You say that you needed a new bed after your surgery. The Plan denied your request. The Plan says the provider is not a Medicare certified supplier.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that MattressFirm entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the bed purchased on June 3, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopy (47562).You asked the Planto pre-approve the laparoscopy. You say that this procedure is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says that the ultrasound and CT Scan do not support that surgery is medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 laparoscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports that the enrollee has impaired gallbladder contractility most likely due to chronic cholecystitis.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 laparoscopy have been met. Therefore, we decided that the Plan has to pre-approve a laparoscopy (47562). 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe chest x-ray provided on October 16, 2019.You asked the Plan to waive the copayment forthe chest x-ray. You say that you have had radiology and lab work done before and never had a copayment. You say that this should be covered in full.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 $40 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $40 copayment for the chest x-ray. The chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that youwere only charged a copayment for the x-ray. 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 chest x-ray provided on October 16, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe radiation treatment management services provided from August 15, 2019 to September 20, 2019.You asked the Plan to waive the copayment forthe radiation treatment management services. You say that you only saw the doctor once a week and paid your copayment. You say you are questioning the charge of $198.81.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each Medicare-covered visit with an in-network specialist. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $45 copayment for an in-network specialist office visit.You have been asked to pay a $198.81 copayment for each date of service for the radiation treatment management services. The radiation treatment management services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. You have been asked to pay the allowed amount for each date of service because this amount is less than the standard copayment amounts. The standard is a $45 per 5 days of physician services per date of service. ($45 x 5 = $225).The record shows the code for the radiation treatment management services represents 5 days of physician services. Therefore, thisresultsin a 5-time specialist copay for each date of service. Please note, the record shows it is not necessary that the radiation therapist personally examine the patient during each day for the weekly treatments management code to be payable.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe radiation treatment management services provided from August 15, 2019 to September 20, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 20, 2019 to September 18, 2019.
You asked the Plan to pay for the 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 have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
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 pay for the skilled nursing services. Our reviewer 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 have to pay for the skilled nursing services provided from August 20, 2019 to September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 19, 2019 to the 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 July 19, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 17, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid 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 drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for endovenous ablation therapy for the enrollee.
You asked the Plan to pre-approve the anesthesia. You say that this is medically necessary. The Plan denied your request. The Plan says anesthesia is not separately billable in these cases.
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 anesthesia. Our reviewer says that the requested anesthesia is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity of anesthesia for the procedures in question. There is documentation that the enrollee denies anxiety, depression, or psychological sleep disturbances. There is no documentation that the patient is having lifestyle limiting symptoms despite the current use of measured, medical grade compression stockings. Her BMI puts her at the cusp of "severe or extreme" obesity but this is not noted in the medical record as a potential contributor to her end of the day leg discomfort or anesthetic risk. It is unclear why she is slated for 4 or five ablative procedures from the outset. There is documentation that there is no ulceration. The health plan considers the choice of anesthetic to be a component of care for the procedure and not separately billable. There is insufficient documentation in the medical record on which to base an overturn of this determination on the basis of medical necessity. 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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for endovenous ablation therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on May 13, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that the supplier record must corroborate the documentation in the beneficiary's medical documentation. A review of the file does not show that the the medical record does not contain mention of back pain or notes need for the back brace.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to theenrollee on May 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367), radiographic/surgical implant index (D6190), surgical placement of implant body: endosteal implant (D6010 x2), second stage implant surgery (D6011 x2), prefabricated abutment (D6056 x2), and panoramic x-ray (D0330).
You asked the Plan to pre-approve the cone beam CT capture and interpretation, radiographic/surgical implant index, endosteal implants, two second stage implant surgery, prefabricated abutments, and panoramic x-ray. The Plan denied your request. The Plan says cone beam CT capture and interpretation, radiographic/surgical implant index, endosteal implant, second stage implant surgery, and prefabricated abutment are not listed as covered benefits. The Plan also says that the panoramic x-ray exceeds the frequency limitation under the enrollee's benefit 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, cone beam CT capture and interpretation, radiographic/surgical implant index, surgical placement of implant body: endosteal implant, second stage implant surgery, and prefabricated abutment are not among those covered under this benefit. The contract clearly states that panoramic x-rays (D0330) are limited to one procedure every three plan years. The record shows that the enrollee received a panoramic x-ray on June 11, 2019 and the enrollee's panoramic x-ray benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367), radiographic/surgical implant index (D6190), surgical placement of implant body: endosteal implant (D6010 x2), second stage implant surgery (D6011 x2), prefabricated abutment (D6056 x2), and panoramic x-ray (D0330).