Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 physical therapy (PT) visits.
You asked the Plan to pre-approve 18 PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 18 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.
Our physician reviewer found based on the medical records provided there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Records do not document complexity of the enrollee's condition which would necessitate further skilled skilled physical therapy visits beyond what have already been approved. Further utilization of the home exercise program appears appropriate after completion of the 18 recently approved visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 18 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 physical therapy (PT) visits
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 an IRF admission covered. The Plan denied your request. The Plan says an IRF admission does not appear to be 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 looked at the file, and Medicare rules. In this case the Plan provided documentation showing that several requests were sent to the provider for medical records to support the appeal. The requested medical records were not received by the Plan. Based on the available information, we were unable to determine that Medicare rules for coverage of IRF care have been met.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered medication provided from July 23, 2021, to August 5, 2021.
You asked the Plan to pay for self-administered medication. You say that the hospital would not let you bring your own medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered medication provided from July 23, 2021, to August 5, 2021.
Benefits for self-administered medication 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 the office visit and laboratory work provided on February 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and laboratory work. You say that the enrollee has relocated and was over 500 miles away from their primary care physician. 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the office visit and laboratory work provided on February 2, 2021, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services provided on June 7,
2021.
You asked the Plan to waive the copayment for the urgent care services. You say that you went to the urgent
care center but they told you they couldn't treat you and to go to the hospital. 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 $25
copayment for urgent care services.
You have been asked to pay a $25 copayment for the urgent care services. This copayment applies regardless
of the extent of services you receive. 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 urgent care
services provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus vaccine (90715, 90471) provided on July 22, 2021.
You asked the Plan to pay for the tetanus vaccine. You say that the vaccine was medically necessary and
should be covered. The Plan denied your request. The Plan says this vaccination is not eligible for coverage
under the Part B medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the tetanus
vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus vaccine (90715, 90471)
provided on July 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.
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 48 one-way transportation trips when each one-way trip does not exceed 50 miles.
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 additional routine transportation mileage
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 15, 2021.
You asked the Plan to waive the copayment for emergency care. You say that if your primary care provider had treated your condition properly you would not have needed emergency care. 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 $120 copayment for emergency care.
You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Emerg Auto-Emersion Therapy system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this request performs the same purpose as equipment already available to the enrollee.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device exceeds the enrollee's medical needs as it has deluxe features which are not medically necessary and the enrollee's wounds are improving with the current treatment and equipment.
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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Emerg Auto-Emersion Therapy system
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation using a stretcher.
You asked the Plan to pre-approve routine transportation using a stretcher. You say that the requested services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 unlimited rides up to 30 days upon referral from a clinical advocate, immediately following inpatient hospital discharges or skilled nursing facility stays with restrictions.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation using a stretcher
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 stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation provided indicating medical necessity for LTACH
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where they are currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) visits you had from May 24, 2021, to July 7, 2021.
You asked the Plan to waive the copayments for the ER visits. You say that you had to return to the ER for rabies treatment. You said that you should not be penalized because the rabies treatment was not available in a less costly setting. The Plan denied your request. The Plan says you were charged these copayments 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 $90 copayment per visit for emergency room services.
You have been asked to pay a $90 copayment per visit for the ER visits. These copayments apply regardless of the reason for the ER visits. 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 the emergency room (ER) visits you had from May 24, 2021, to July 7, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (80307) provided on April 21, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says that the frequency relationship criteria has not been met.
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 rules also say that it is not appropriate to report more than twelve (12) presumptive urine drug testing (UDT) (code 80305, 80306, or 80307) services per calendar year. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan states that the testing at issue was denied due to frequency, the Plan has not provided any documentation showing when the enrollee previously received this testing. Therefore, we decided that the Plan has to pay for drug testing (80307) provided on April 21, 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 physician services (99223) provided June 14, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is 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.
We find that CPT code 99223 is not supported in the medical record. Specifically, this procedure is included in the global surgery period for a surgical procedure performed on the same date of service (11043). Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99223) provided
June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), limited oral evaluation - problem focused (D0140), endodontic therapy, premolar tooth (excluding final restoration) (D3320), crown - porcelain/ceramic (D2740), gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212), prefabricated post and core in addition to crown (D2954), and intraoral - periapical first radiographic image (D0220) provided October 13, 2020.
You asked the Plan to pay for the dental cleaning, limited oral exam, endodontic therapy, gingivectomy or gingivoplasty, prefabricated post and core and intraoral x-rays. You say that you were unaware that your dentist needed to be enrolled in Medicare and will see a different dentist in the future. The Plan denied your request. The Plan says services provided by a dentist who has opted out of Medicare are not 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. The Plan covers the dental cleaning, limited oral exam, endodontic therapy, gingivectomy or gingivoplasty, prefabricated post and core and intraoral x-rays when the services are provided by a licensed dental provider who accepts Medicare patients in the United States and has not opted out of Medicare. We looked at the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning, limited oral exam, endodontic therapy, gingivectomy or gingivoplasty, prefabricated post and core and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), limited oral evaluation - problem focused (D0140), endodontic therapy, premolar tooth (excluding final restoration) (D3320), crown - porcelain/ceramic (D2740), gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212), prefabricated post and core in addition to crown (D2954), and intraoral - periapical first radiographic image (D0220) provided October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgical services provided on
June 18, 2021.
You asked the Plan to waive the coinsurance for the outpatient surgical services. You say that the provider told
you that these services would be covered in full, and you would not owe anything for this care. The Plan denied
your request. The Plan says the provider in this case is not part of the Plan's network. Outpatient surgical
services received out-of-network require 50% coinsurance; this claim was processed 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 50%
coinsurance for out-of-network outpatient surgery services.
You have been asked to pay 50% coinsurance for the outpatient surgical services which were performed by an
out-of-network provider. 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 coinsurance for outpatient surgical
services provided on June 18, 2021.
Please note: We have read your letter and you have expressed that you are dissatisfied with potentially
incorrect information given to you by the out-of-network provider. Unfortunately, out-of-network providers are
not contracted or affiliated with the Plan, and any grievances with an out-of-network provider should be
submitted to the provider directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a fungal pathogen evaluation (87481, 87551, 87798) provided on July 13, 2021.
You asked the Plan to pay for a fungal pathogen evaluation. You say that this was medically necessary. The Plan denied your request. The Plan says this is experimental.
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 pay for a fungal pathogen evaluation. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the nucleic acid test performed on the enrollee's fungal toenail specimens was above and beyond the enrollee's medical needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fungal pathogen evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a fungal pathogen evaluation (87481, 87551, 87798) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on June 8, 2021, by an OON
provider.
You asked the Plan to pay for drug testing. You say that you are a specialized laboratory that performs drug
monitoring, in good faith, at the request of the ordering physician who sends us the authorizing requisition
form. The Plan denied your request. The Plan says that neither this provider, nor the referring provider is a
network provider with the Plan. The Plan also says that they have also determined that these services are not
urgent or emergent, nor were they approved in advance.
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 Plan contract says you must obtain authorization from the
Plan prior to seeking care from an out-of-network provider.
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 drug testing (G0480) provided on June 8, 2021, by
an OON provider