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

We decided that the Plan does not have to pre-approve the non-emergency transportation services.
You asked the Plan to pre-approve the non-emergency transportation services. You say that it is medically
necessary for the enrollee to receive these transportation services. The Plan denied your request. The Plan says
these services are not medically reasonable and necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 non-emergency transportation
services. Our reviewer says that the requested non-emergency transportation services are not medically
necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knees
and requires transportation to and from an orthopedic surgeon evaluation. The record indicates that there has
been a delay in obtaining wheelchair transportation. The record does not indicate that other modes of
transportation would endanger the enrollee's health. The record does not indicate that the patient's clinical
condition is such that other methods of transport are contraindicated. The elements of the coverage criteria are
not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-emergency transportation services have not been met. Therefore, we
decided that the Plan does not have to pre-approve the non-emergency transportation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided from March 28, 2021, to April 6, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with E43. 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 services. Our reviewer says that the use of diagnosis code E43 is not supported by the records provided. Our physician reviewer found that the enrollee is a 78-year-old male with poor oral intake from abdominal pain and nausea. CT scan showed large partial bowel obstruction, obstructive uropathy of left kidney and hydronephrosis and hydroureter, metastatic lesions to lungs and liver related to sidewall tumor at the site of previous prostatectomy. Body fat and muscle mass were described as normal, and the enrollee was tolerating diet in the hospital. Severe protein-calorie malnutrition was listed as a diagnosis. Based on the provided documentation from this admission, the enrollee did not meet criteria for severe protein-calorie malnutrition to justify this secondary diagnosis.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from March 28, 2021, to April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a restorative procedure (D2999), crown (D2740) for tooth #30, and core buildup, including any pins when required (D2950) for tooth #30.    You asked the Plan to pre-approve the restorative procedure, crown, and core buildup. You say that you had a dental visit in 2020 when you received a new crown, but you were unhappy with the results from the original provider and would like the tooth to be retreated by another provider. The Plan denied your request. The Plan says the unspecified restorative procedure is not a covered benefit. The Plan also says that crowns are allowed once in a five-year period, and core buildups are allowed once in a two-year period.  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 unspecified restorative procedure (D2999) is not among those covered under this benefit. The contract says that crowns are covered once in a five-year period from the seat date and crown buildups are limited to once per tooth within two years of restoration on the same tooth. The record shows that you received a crown (D2740) on tooth #30 on March 19, 2020 and prefabricated post and core in addition to a crown (D2954) on tooth #30 on March 3, 2020 and your crown and crown buildup benefits for tooth #30 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a restorative procedure (D2999), crown (D2740) for tooth #30, and core buildup, including any pins when required (D2950) for tooth #30.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Ziconotide injection (J2278) and refilling and maintenance of implantable pump or reservoir for drug delivery (95990) provided on May 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the Ziconotide injection and refilling and maintenance of implantable pump or reservoir for drug delivery. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says the prior authorization request submitted for this service to be rendered by the OON provider was denied, and you were redirected to a contracted provider for approval of these same services. The Plan also says that on May 25, 2021 you chose to have the services performed by the OON provider.   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 had network providers available who could have provided 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 Ziconotide injection (J2278) and refilling and maintenance of implantable pump or reservoir for drug delivery (95990) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, 87801) provided on May 18, 2021.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, 87801) provided on May 18, 2021.
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 enrollee is high risk for pulmonary decompensation which is not safe to monitor at home. You also say that wound care is needed for bilateral lower extremity wounds. The Plan denied your request. The Plan says the services the enrollee requires, including their home oxygen, and intermittent wound care and therapy, can safely be received at a different setting.
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 SNF services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography (95870), the somatosensory testing (95938), the central motor evoked potential study (95939), and the continuous intraoperative neurophysiology monitoring (G0453) rendered by the out-of-network (OON) provider on September 29, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the needle electromyography (95870), the somatosensory testing (95938), the central motor evoked potential study (95939), and the continuous intraoperative neurophysiology monitoring (G0453) rendered by the out-of-network (OON) provider on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on August 23, 2021.
You asked the Plan to pay for the preventive procedure. You say that you believe this claim should be paid at 100% per the Plan's Evidence of Coverage, as you could not receive your benefit without your dentist using personal protective equipment due to the Coronavirus requirements. The Plan denied your request. The Plan says this service is not a covered expense under your dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) provided on August 23, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a laryngoscopy and speech therapy
services provided on August 19, 2021.
You asked the Plan to waive the copayments for a laryngoscopy and speech therapy services. You say that you
disagree with how high the charges are when you previously paid a lesser copayment for the same procedure.
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 $225
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers. Your contract with the Plan also clearly says that you must pay a $35 copayment for outpatient
rehabilitation services.
You received a laryngoscopy at an outpatient hospital facility on August 19, 2021. A laryngoscopy is
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $225 copayment.
You received speech therapy on August 19, 2021. Therefore, you are responsible to pay the $35 copayment.
The total amount you owe is: $260.
You have been asked to pay the total copayment amount of $260 for a laryngoscopy and speech therapy
services. A laryngoscopy falls within the outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers benefit category. Speech therapy services fall within the outpatient
rehabilitation 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 copayments for a
laryngoscopy and speech therapy services provided on August 19, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the therapeutic procedure (97110) provided on January 25, 2021.
You asked the Plan to pay for the therapeutic procedure. You say that you would like reconsideration because this provider is not a home health agency. The Plan denied your request. The Plan says that these services were billed on an inappropriate claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the records clearly indicate that this provider is not a home health agency. The documentation also shows that these services were rendered in the member's assisted living facility. It would be inappropriate for this provider to bill for these services on a home health claim. The Plan has not forwarded any additional evidence as to why this service cannot be paid as billed. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated. Therefore, we decided that the Plan has to pay for the therapeutic procedure (97110) provided on January 25, 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: SNF
Decision: Favorable

 We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from August 19, 2020, through August 31, 2020.  You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that this claim has been billed with an invalid code.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied payment for the SNF care by citing that a Health Insurance Prospective Payment System (HIPPS) code submitted on the claim is invalid. However, there is no evidence provided of what HIPPS code the Plan is finding invalid for payment. In addition, there is no notice given on what makes this HIPPS code invalid. The Plan has not cited a rule that is preventing them from paying for these SNF services. The Plan has not made a reasonable and diligent attempt to substantiate their denial. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from August 19, 2020, through August 31, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an extended skilled nursing facility (SNF) stay.  You asked the Plan to pre-approve the extended SNF stay. You say that you broke your ankle, are currently in a cast that you cannot put any weight on. You also say that you cannot get yourself into your wheelchair or a vehicle, and if you go home, you will not be able to get to your appointments. The Plan denied your request. The Plan says your continued needs can be met through a lower level of care, such as increased caregiver support. The Plan also says that the available records do not indicate any ongoing daily skilled needs and that your ongoing needs are custodial in nature.  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 extended SNF stay. 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 extended SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve an extended skilled nursing facility (SNF) stay.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on
September 2, 2021 to September 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that please see pages 84 and 88 of the 2021
Evidence of Coverage which clearly states that outpatient mental health care is covered. Please process this
claim as soon as possible. The Plan denied your request. The Plan says the provider is a licensed marriage and
family therapist and a licensed mental health counselor and is not an eligible Medicare provider.
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 the individual psychotherapy services
(90837) provided on September 2, 2021 to September 23, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204), the laboratory service (83986), and
the measurement of post-voiding residual urine (51798) rendered by the out-of-network (OON) provider on
August 31, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 for the office visit (99204), the laboratory service (83986), and the measurement of
post-voiding residual urine (51798) rendered by the out-of-network (OON) provider on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 10.
You asked the Plan to pre-approve the dental service. You say that your tooth is very thin and breaks very
easily. You also say that you would like your tooth to be fixed as soon as possible. The Plan denied your
request. The Plan says the requested tooth already has a crown on it.
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 dental
service 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 dental service. Our reviewer says
that a crown for tooth # 10 is not medically necessary. Our physician reviewer found the provided radiograph
and the plan indicates that the enrollee has a crown on this tooth already. The reviewer found that there are no
further information is available for review. The reviewer found that the elements of the coverage criteria are not
satisfied and therefore is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental service have not been met. Specifically, the file shows that this tooth
already has a crown. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for
tooth # 10.