Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member needs admission to acute inpatient rehab. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for left leg cellulitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the x-ray of the chest (71045) and x-ray of the abdomen (74018) provided on January 23, 2021.
You asked the Plan to pay for the x-rays. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation is missing notes.
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 record includes clinical information supporting that the billed services were rendered. The Plan has failed to forward any information indicating why these services are not payable. It is the burden of the Health Plan to substantiate their denial with evidence. This denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the x-ray of the chest (71045) and x-ray of the abdomen (74018) provided on January 23, 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 pay for critical care services provided on April 10, 2021.
You asked the Plan to pay for critical care services (99291). You say that the Plan should pay these claims. The Plan denied your request. The Plan says the claim is a duplicate to the claim paid on May 6, 2021.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99291, for date of service April 10, 2021 with the same provider, was paid for on May 6, 2021. Based on this information, we decided that Medicare rules for coverage of critical care services
(99291) have not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided on April 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on April 22, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you should not have to pay for these services. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. The Plan also says that the intraoral complete series of radiographic images is a covered benefit, but you have exceeded the frequency limit of one every 5 years.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limits for these services on April 28 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300, E2377, E2313, and E2311).
You asked the Plan to pre-approve the wheelchair components. You say that the features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but not the seat elevation feature (E2300) or attendant control (E2331) are not covered.
The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules also say that the electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Therefore, we decided that the Plan does not have to pre-approve group 3 power mobility device features (E2300, E2377, E2313, and E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 8, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery provided on January 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cataract surgery. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the cataract surgery provided on January 15, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation provided on November 25, 2020.
You asked the Plan to pay for electrical stimulation. The Plan denied your request. The Plan says no medical records were provided.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that the Plan did not receive sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of electrical stimulation have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92012) and pay for an eye refraction (92015) provided on June 1, 2021.
You asked the Plan to waive the copayment for a medical eye exam and pay for an eye refraction. You say that the service provided was a routine visit and the provider is part of the network. The Plan denied your request. The Plan says the copayment you are being charged is correct. The Plan also says that an eye refraction is only covered when performed as a routine service.
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 contract says you pay a $35 copayment for each visit to a specialist such as an ophthalmologist or optometrist, for Medicare-covered benefits. The Plan contract also says that a refraction is covered when it is obtained through one of the Plan's routine vision service vendors. We looked at the file and the Plan's rules. The records show that the provider did not perform a routine eye exam. The records also show that you were seen for a medical diagnosis for the presence of vitreous membranes and strands. The EOC confirms $35 is the required copayment for this service. An eye refraction is covered by the Plan when it is performed as a routine screening by a participating routine vision service vendor. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam and an eye refraction have not been met. Therefore, we decided that the Plan does not have to waive the copayment for a medical eye exam (92012) and pay for an eye refraction (92015) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays provided on April 15, 2021.
You asked the Plan to pay for the intraoral x-rays. You say that you told them to proceed only with the services that were covered by the Plan. You say that you cannot pay a $491 bill for a service you did not ask for and the charge should be reduced. The Plan denied your request. The Plan says the claim was reprocessed according to the in-network benefits for the comprehensive oral evaluation, bitewing x-ray, panoramic x-ray and prophylaxis. The intraoral x-rays remain denied as they are not a covered benefit.
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 intraoral x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard.
You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says the service is not a covered benefit.
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 pre-approve the occlusal guard.
Appeal type: Practitioner Services
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 the requested procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Intracept procedure is considered experimental/investigational for the enrollee's condition.
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 for the treatment of lower back pain. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the diphtheria and tetanus vaccine and immunization administration provided on March 23, 2021.
You asked the Plan to pay for the diphtheria and tetanus vaccine and immunization administration. You say that you were told you need to have a booster shot so you did as instructed. You say that you found nothing that says you have to go to a drug store for a shot and the claim should be paid for $131. The Plan denied your request. The Plan says this is a Part D covered vaccine.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the diphtheria and tetanus vaccine and immunization administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the diphtheria and tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the diphtheria and tetanus vaccine and immunization administration provided on March 23, 2021.
Benefits for the diphtheria and tetanus vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 14, 2021.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on March 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical procedure to place a metal device placed in between the bones of the lower back.
You asked the Plan to pre-approve the spinal decompression and interspinous process decompression systems. You say that the surgical procedure is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that use of this device is better than an alternative spinal surgery.
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 spinal decompression and interspinous process decompression systems. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Spinal decompression and interspinous process decompression systems for the treatment of lumbar spinal stenosis (e.g., Interspinous process decompression (IPD), Minimally invasive lumbar decompression (mild ) are unproven and not medically necessary due to insufficient evidence of efficacy. The items/services at issue in this case are not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal decompression and interspinous process decompression systems have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical procedure to place a metal device placed in between the bones of the lower back
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D imaging services (76377) provided April 14, 2021.
You asked the Plan to pay for the imaging services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 76377 is not supported in the medical record. Specifically, the documentation does not show an appropriate primary imaging procedure billed. Without a valid primary procedure, this service cannot be paid. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for 3D imaging services (76377) provided April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for diagnostic arteriography/venography
(01916) rendered by the out-of-network (OON) provider on October 15, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the anesthesia for diagnostic arteriography/venography (01916) rendered by the outof-
network (OON) provider on October 15, 2020.