Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on October 22,
2020, to April 15, 2021.

You asked the Plan to pay for psychotherapy services. You say that the provider of the services at issue was
your doctor previously and that you needed treatment during an issue with your medical coverage. The Plan
denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834)
provided on October 22, 2020, to April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on April 3, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no 
payable service. 
 
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 April 3, 2021. 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 ambulance response and treatment, no transport 
(A0998) provided on April 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided on
May 6, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that your primary care physician refused to see you and you went to the emergency room for treatment. The Plan denied your request. The Plan says the claim processed correctly with the appropriate copayment.
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 $90 copayment for emergency room services. Emergency room services falls within the Emergency Care 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 emergency room services provided on May 6, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on September 
15, 2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you were never told that you 
would owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct 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 $30 
copayment for podiatry services.  
 
You have been asked to pay a $30 copayment for podiatry services. Podiatry services fall within the podiatry 
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 copayment for podiatry services provided 
on September 15, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs services for a short time. The Plan denied your request. The Plan says that the enrollee does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our physician reviewer found that the enrollee has documented skilled nursing needs. He requires wound care that he, nor his son, cannot provide. The enrollee has documented skilled therapy needs. He is only able to walk a few feet. The documentation does not yet show a plateau in function. Daily skilled services are reasonable to establish a maintenance program, prevent deterioration of his condition and determine his functional capacity. The enrollee's care needs cannot be provided at a lower level of care. Therefore, the requested services are considered medically reasonable and 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 SNF services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Coronavirus vaccination, first dose (0001A) provided on January 20, 2021.
You asked the Plan to pay for a Coronavirus vaccination. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must submit Coronavirus vaccine administration claims to Original Medicare for administrations in 2020 and 2021. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Coronavirus vaccination have not been met. Specifically, the request is for a Coronavirus vaccine administration in 2021. Original Medicare is responsible for Coronavirus vaccine administrations in 2020 and 2021. Therefore, we decided that the Plan does not have to pay for a Coronavirus vaccination, first dose (0001A) provided on January 20, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. 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
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for a shoulder arthroplasty (23472) provided on April 26, 2021.

You asked the Plan to pay for surgical assistant services for a shoulder arthroplasty. You say that the requested procedure was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for a surgical assistant have not been met.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services for a shoulder arthroplasty (23472) provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on March 10, 2021.

You asked the Plan to pay for the drug testing. You say that this testing should be paid due to medical necessity. The Plan denied your request. The Plan says the documentation does not support the reported POS code on the claim.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 

We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollees needs can be met at a lower 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 in the Medicare rules section 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. 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 facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 catheter leg bags (A4358).

You asked the Plan to pre-approve 15 catheter leg bags. You say that the additional bags are medically necessary. The Plan denied your request. The Plan says the requested amount exceeds the allowable. The 2 allowable bags have been approved.

The Plan must follow Medicare rules. Medicare rules say that each month 2 urinary drainage collection systems bags will be covered. 

We looked at the file and Medicare rules. Only 2 of this type of catheter bag can be covered per month. The 15 requested exceeds the allowed amount. Based on this information, we decided that Medicare rules for coverage of 15 catheter leg bags have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 catheter leg bags (A4358).
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 medically necessary. The Plan denied your request. The Plan says 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 

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 pay for the special anesthesia services provided on February 6, 2020, billed with code 99100.

You asked the Plan to pay for the anesthesia services as billed. You say that it is felt this claim should be paid due to medical necessity for the anesthesia services. The Plan denied your request. The Plan says the anesthesia provided has been approved; however, code 99100 is not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule. This means payment for this is bundled in payment made for unspecified other services. Based on this information, we decided that Medicare rules for coverage of the anesthesia services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on February 6, 2020, billed with code 99100.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mud guard kit, back rest frame and mounting block 
(K0801). 
 
You asked the Plan to pre-approve the mud guard kit, back rest frame, and mounting block. You say that you 
would like reconsideration because the requested accessories are medically necessary. The Plan denied your 
request. The Plan says the mud guard does not serve a medical purpose and the approved wheelchair includes 
mounting hardware. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The mud guard at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Additionally, the 
requested hardware is included in the approved wheelchair. This hardware cannot be requested separately. 
Therefore, we decided that the Plan does not have to pre-approve the mud guard kit, back rest frame and 
mounting block (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the duplex scan you received on June 24,
2021.
You asked the Plan to reduce the copayment for the duplex scan. You say that you were told repeatedly that
your copayment would only be $30. You stated that it would have been cheaper for you to go out-of-network.
The Plan denied your request. The Plan says you were charged this copayment 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 $155
copayment for radiological diagnostic services.
You have been asked to pay a $155 copayment for the duplex scan. The duplex scan falls within the
radiological diagnostic services benefit category. The $30 copayment you quoted in your appeal applies only to
non-radiological diagnostic services (see page 4-43 of your Evidence of Coverage.) The duplex scan you
received is a radiological service. 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 reduce the copayment for the duplex scan you
received on June 24, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal endoscopy (31231) and outpatient hospital clinic 
visit (G0463) provided on March 12, 2021. 
 
You asked the Plan to pay for the nasal endoscopy and outpatient clinic visit. You say that you would like this 
claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal 
condition. 
 
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 the nasal endoscopy (31231) and outpatient hospital clinic 
visit (G0463) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a COVID Clinic.

You asked the Plan to pre-approve an out-of-network referral to a COVID Clinic. You say that the requested out-of-network referral to a COVID Clinic is medically necessary. The Plan denied your request. The Plan says the requested out-of-network referral to a COVID Clinic is not medically necessary.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 an out-of-network referral to a COVID Clinic. Our reviewer says that the requested out-of-network referral to a COVID Clinic is not medically necessary. Our physician reviewer found the record indicates that the enrollee wishes to be seen at an out of network long term COVID Clinic, claimed to be the only one in the country. The record indicates that the enrollee had an aortic valve replacement in February 2021 and continues to undergo cardiac rehabilitation. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an out-of-network referral to a COVID Clinic have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to a COVID Clinic.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed Orthovisc or Monovisc. There is no indication that these drugs would likely be less effective and/or likely to have adverse effects for the enrollee. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane for the enrollee.