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

We decided that the Plan does not have to pre-approve the consultation and pulmonary testing to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the consultation and the pulmonary testing. You say that local doctors have been unable to help. You say the request was approved for October 18, 2021 but was denied for October 19, 2021. The Plan denied your request. The Plan says the provider is 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 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 the consultation and pulmonary testing to be provided by an out-of-network (OON) provider.
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 SNF services. You say that you do not have the strength to safely take care of yourself at home. The Plan denied your request. The Plan says you do not require a skilled therapist, and you have no skilled nursing needs.
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 from a nursing perspective, you received oral medications, had stable vital signs, and were treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at an independent to standby assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hand surgery you had at an ambulatory surgery center on June 3, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were not expecting a bill for this service because your first surgery failed. You don't think you should be billed for something that didn't work for you. 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 $250 copayment for outpatient surgery.
You have been asked to pay a $250 copayment for the outpatient surgery. This copayment applies regardless of the outcome of the surgery. 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 the outpatient hand surgery you had at an ambulatory surgery center on June 3, 2021.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says the enrollee does not have complex rehabilitation, medical, or nursing needs. The Plan says that the enrollee's needs can be met at an alternate level of care.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a scrotal abscess, pyelonephritis, and transient ischemic attack. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 you are living at home with weakness and trouble ambulating. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. Therefore, 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: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services coded A0428 provided on June 18, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that A0428 is the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. We looked at the file and Medicare rules. Review of the file shows that these services were billed with code A0428, which is the appropriate code to be billed when the enrollee is pronounced dead after the ambulance is called. In addition, the appropriate modifier of QL was billed with this code as well. In addition to the QL modifier, providers report modifier QM or QN. The documentation shows that in addition to the QL modifier, the claim was also billed with the QN modifier. The Plan did not give appropriate reasoning as to why the code billed was denied. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services coded A0428 provided on June 18, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology consultations and treatment to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the neurology consultations and treatment. You say that you want to seek
another doctor but have limited resources in your area. The Plan denied your request. The Plan says the
provider is 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 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. The records provided for review do not show that the services at
issue are urgent or emergent.
Therefore, we decided that the Plan does not have to pre-approve the neurology consultations and treatment to
be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic care to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the orthopedic care. You say that you want to see the doctor who performed
the original surgery in 2008 because he is aware of your case. The Plan denied your request. The Plan says the
provider is 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 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. The records provided for review do not show that the service at
issue is urgent or emergent.
Therefore, we decided that the Plan does not have to pre-approve the orthopedic care to be provided by an outof-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 1, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you received the ultrasound at a
specialist's office not a hospital facility. 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 $75
copayment for ultrasounds at all locations of service.
You have been asked to pay the allowed amount of $39.42, which is less than the $75 copayment for an
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies
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 an ultrasound provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive periodontal evaluation (D0180), unspecified preventive service (D1999 x 2), extractions (D7140 x 4), bone replacement graft (D7953), implants (D6010 x 2), and non-intravenous conscious sedation (D9248) provided from December 2, 2020, to December 15, 2020.
You asked the Plan to pay an additional amount for the dental services. You say that according to your benefits, you were covered for extractions, oral surgery, dental surgery anesthesia, and implants. You say that your
booklet also indicates you have an annual maximum benefit for dental services of $1,000. You also say that you would like to be reimbursed $1,000 for the dental services you already paid for. The Plan denied your request. The Plan says the bone replacement graft, unspecified preventive service, implant, and non-intravenous conscious sedation are not listed as covered services. The Plan says that the provider in this case is out of network. The Plan says that out of network dentists may bill you for any amount greater than what the Plan pays. The Plan also says that the dental maximum only applies to services that are covered. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft, unspecified preventive service, implant, and non-intravenous conscious sedation are not among those covered under this benefit. The record shows that out of network dentists may bill you for any amount greater than what the Plan pays. Additionally, you may only be reimbursed for dental services that are covered by the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive periodontal evaluation (D0180), unspecified preventive service (D1999 x 2), extractions (D7140 x 4), bone replacement graft (D7953), implants (D6010 x 2), and non-intravenous conscious sedation (D9248) provided from December 2, 2020, to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional pair of glasses.
You asked the Plan to pre-approve an additional pair of glasses. You say that if the cancer returns, you'll be in danger of losing eyesight, an eye or the cancer spreading to your brain. You say that another pair of should be approved using the same medically necessary criteria. The Plan denied your request. The Plan says only one pair of eyeglasses is covered every 2 years and you have already received a pair of glasses this year.
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 one pair of lenses and frames or contact lenses is covered every 2 years. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an additional pair of prescription sunglasses have not been met. The Plan paid for the pair of glasses prescribed on September 3, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve an additional pair of glasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you need the requested items for your swollen legs and that the Plan's 2021 EOC says that the requested items are covered. The Plan denied your request. The Plan says rules for coverage for compression stockings have not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional non-emergency one-way trips.
You asked the Plan to pre-approve the additional trips. You say that you need additional rides because you have a heart condition and glaucoma and need transportation to make it to appointments for those conditions. The Plan denied your request. The Plan says you have used all of your available 40 one-way trips allowed under your contract. The Plan also says that extra one-way trips cannot be approved.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of up to 40 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 15 additional non-emergency one-way trips.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 5 additional home health skilled nursing visits.
You asked the Plan to pre-approve home health services. You say that these services are medically necessary
for the enrollee's condition. The Plan denied your request. The Plan says that additional home health skilled
nursing services are not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our reviewer
says that the requested home health skilled nursing services are medically necessary. Our physician reviewer
found Based on the documentation provided, the enrollee does have documented skilled nursing needs. While
the enrollee's colostomy is now a couple months old, the enrollee appears to have a new Foley catheter and is
experiencing orthostatic hypotension with syncope. Ongoing monitoring by a visiting skilled nurse is medically
necessary and reasonable for the patient's condition.
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 services have been met. Therefore, we decided that the Plan has to
pre-approve 5 additional home health skilled nursing visits.
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: 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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 was admitted for malnutrition, dehydration and failure to thrive and had
a scheduled Whipple procedure and aortic valvuloplasty. The enrollee's medical problems are stable. There are
no complex nursing or rehabilitation needs. The documentation does not support that the enrollee that the enrollee requires an intensive rehabilitation therapy program. The enrollee's 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.