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

We decided that the Plan does not have to pay for pain management services provided on February 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.
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 pain management services provided on February 9, 2021 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records, there are no identifiable skilled nursing service needs. The records do not show the enrollee requires skilled nursing or therapy services on a daily basis. The enrollee's condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty (15823).
You asked the Plan to pre-approve blepharoplasty. You say that your doctor strongly recommends this surgery. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty may be considered reconstructive to correct visual impairment when photographs demonstrate the eyelid abnormalities necessitating the procedures. We looked at the file and Medicare rules. The submitted medical records do not include photographs as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty (15823).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterology provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterology provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation.
You asked the Plan to pre-approve the requested services. You say that the enrollee continues to report persistent depressed mood. The Plan denied your request. The Plan says the enrollee does not have severe major depressive disorder.
The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered under certain medical indications. 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 enrollee has a diagnosis of bipolar disorder, current episode depressed, severe with psychotic features. He has tried a number of pharmacologic agents from different categories including Tegretol, trazodone and Geodon which he currently takes. He has previously been tried on Remeron, Wellbutrin XL, Abilify and Effexor XR. He did have electroconvulsive treatment (ECT) in the past with little success. He has documentation of cognitive psychotherapy. This enrollee is not indicated for the requested service. He does not meet the coverage criteria in that his diagnosis is not Major Depressive Disorder but rather Bipolar Disorder. 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 transcranial magnetic stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not have intensive therapy needs.
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 physician reviewer found that the enrollee was admitted to the acute hospital for surgical evacuation of a lower extremity hematoma, acute blood loss anemia, and lower extremity cellulitis. His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 17, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that this is a preventative scan, and you
should not be responsible for the charges. 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 $150
copayment for advanced radiology services.
You received a CT scan of the thorax on February 17, 2021. A CT scan of the thorax is considered a diagnostic
test, not preventative. Therefore, you are responsible to pay the allowed amount of $140.55, which is less than
the $150 copayment.
You have been asked to pay $140.55 for a CT scan. A CT scan falls within the outpatient diagnostic tests and
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a
CT scan provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier test provided to the enrollee on May 28, 2020.
You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. The Plan says this is an investigational test that provides a risk level of lung cancer.
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 the test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this test is still being investigated. Despite their potential promise, evidence that using such biomarkers would improve the efficiency of lung cancer screening is lacking.
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 test have not been met. Therefore, we decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier test provided to the enrollee on May 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that SNF care is a necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Trilogy home ventilator.
You asked the Plan to pre-approve a Trilogy home ventilator. You say that a home ventilator is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD. 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 a home ventilator.
Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical
records show you have a diagnosis of sleep apnea, restrictive lung disease, obesity hypoventilation syndrome,
and diaphragm dysfunction and chronic respiratory failure as a result. However, you do not have a
neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic
obstructive pulmonary disease. The records also show you have not tried and failed a more conservative
device. Medicare coverage criteria are not met.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Trilogy home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult-sized disposable diapers.
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan denied your request. The Plan says this denial is done in accordance with the plan's stipulations.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve adult-sized disposable diapers.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Januvia.
You asked the Plan to pre-approve Januvia. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Januvia.
Benefits for Januvia 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 provided by an out-of-network provider on October 1, 2020.
You asked the Plan to pay for the office visit. You say that the medical documentation is attached, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 office visit provided by an out-of-network provider on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the face (70486) provided on December 16, 2020, by an out of network (OON) provider.
You asked the Plan to pay for a CT scan of the face. You say that you did not know a referral was required for this kind of procedure. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 computed tomography (CT) scan of the face (70486) provided on December 16, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on January 11, 2021, by an
OON provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The
Plan says that the rendering facility is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 skilled nursing services provided on January 11,
2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that the enrollee needs inpatient rehabilitation and
should go to the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is
correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. 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 Skilled Nursing Facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided necessitating admission to a LTACH. 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 he is 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.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 2, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 says that the Plan has 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet light therapy.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this request cannot be approved at this time.
The Plan must follow Medicare rules. Medicare rules say that ultraviolet light therapy is covered for psoriasis. The enrollee has vitiligo. This request is only covered for psoriasis. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve ultraviolet light therapy.