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

We decided that the Plan does not have to pay for an office visit provided on July 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that service was provided by the primary care provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 an office visit provided on July 12, 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 out of network physician services provided to the enrollee on June 2, 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 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 out of network physician services provided to the enrollee on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge day management (99315) and the subsequent nursing facility care, per day (99308 x 2) rendered by the out-of-network (OON) provider from June 4, 2021, through June 11, 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 nursing facility discharge day management (99315) and the subsequent nursing facility care, per day (99308 x 2) rendered by the out-of-network (OON) provider from June 4, 2021, through June 11, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare.
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 requested services. Our physician reviewer found that the requested interspinous process stabilization device is experimental in spinal surgery. More research is needed to show safety and efficacy. Therefore, the requested device is 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pelvic floor physical therapy.
You asked the Plan to pre-approve pelvic floor physical therapy. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of certain conditions is considered investigational and thus non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pelvic floor physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve pelvic floor physical therapy
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced care planning services coded 99497 provided on October 20, 2020 and the hospital discharge day management services coded 99238 provided on October 23, 2020.
You asked the Plan to pay for the advanced care planning services and the hospital discharge day management services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 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. In this case, we have confirmed that code 99222 for the advanced care planning services is a column II code to column I code 99222. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Inpatient discharge services may only be reported once per day by the same physician or physicians of the same specialty. The documentation shows that code 99239 was previously paid under a different claim number for the date of service October 23, 2020.
Therefore, we decided that the Plan does not have to pay for the advanced care planning services coded 99497 provided on October 20, 2020 and the hospital discharge day management services coded 99238 provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).
You asked the Plan to pre-approve the PMD. You say that the PMD is necessary. The Plan denied your request. The Plan says the documentation does not support medical necessity.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 PMD. Our reviewer says that the service is not shown to be medically necessary. Our physician reviewer found the records do not show that you problems finishing one or more mobility-related activities of daily living (MRADLs) in the home, or that you cannot use a cane or walker to complete your MRADLs. The records also do not show that you do not have enough strength to use a manual wheelchair, or that your home provides enough room for use of the scooter.
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 PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (PMD).
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
July 30, 2021.

You asked the Plan to pay for this service. 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 must 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 July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from April 28, 2021, to April 30, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that too much fluid was removed during the treatment of your kidney disease which caused you to have convulsions. 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 $395 copayment for days 1-5 for inpatient hospital care. The medial records show that you had an inpatient hospital stay from April 28, 2021, to April 30, 2021. Therefore, you are responsible to pay a $395 copayment for days 1-2 (April 28, 2021, to April 29, 2021). The total amount you owe is: $395 (copayment) x 2 (inpatient days) = $790.
You have been asked to pay the total copayment amount of $790 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from April 28, 2021, to April 30, 2021.
We note your complaint that you had too much fluid removed which caused convulsions. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit provided on July 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for clinic visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 a clinic visit provided on July 16, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on February 9, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare doesn't pay for assistants at surgery services furnished in a teaching hospital, which has a training program related to the required medical specialty, and has a qualified resident available, except if the physician certifies that a qualified resident was not available, or if the primary physician has a policy of never involving residents in surgery, or if exceptional medical circumstances exist.
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 assistant surgeon services provided to the enrollee on February 9, 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 the enrollee appears to be improving gradually and should only require short-term additional acute care services at this time that can be successfully completed safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq 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 there is no compendia support for the use of Tecentriq for diagnosis of methothelioma.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee has a diagnosis of mesothelioma. The Food and Drug Administration has not stated that the
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature
from Medicare approved cancer journals were submitted for review. 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Tecentriq for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services (76514, 92134, 92014) provided on September 9, 2020.
You asked the Plan to pay for the ophthalmology services. You say that this service was medically necessary. The Plan denied your request. The Plan says the service was not emergent or pre-approved.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for ophthalmology services (76514, 92134, 92014) provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair accessible van purchased on June 15, 2021.
You asked the Plan to pay for a wheelchair accessible van. You say that a wheelchair accessible van was necessary to enable you to leave the home. The Plan denied your request. The Plan says a wheelchair accessible van is not covered by Medicare.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. A wheelchair accessible van clearly is not used in the home. Therefore, we decided that the Plan does not have to pay for a wheelchair accessible van purchased on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found this device 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on September 23, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 22 for outpatient hospital; however, the services were performed in the inpatient setting and should be billed with
POS code 21. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiology genetic panel (81210, 81323, 81479) provided on February 10, 2020.
You asked the Plan to pay for a cardiology genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a cardiology genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiology genetic panel (81210, 81323, 81479) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic care provided on June 29, 2021.
You asked the Plan to pay for services other than manual manipulation of the spine. You say that no one told you all services would not be covered. The Plan denied your request. The Plan says the contract is clear that all services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic care provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80061, 86803) rendered by the out-of-network (OON) provider on June 28, 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 laboratory services (36415, 80061, 86803) rendered by the out-of-network (OON) provider on June 28, 2021.