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

We decided that the Plan does not have to pre-approvephysical therapy services (91763) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe physical therapy services. You say that the out-of-network provider specializes in treating your condition.The Plan denied your request. The Plan says the services at issue are available from network providers.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services (91763) to be provided by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (G0283), hot or cold packs therapy (97010), and the physical medicine procedure (97139) provided on October 6, 2020.
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 these services are not a covered benefit under your contractual policy or by Medicare.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation (G0283), hot or cold packs therapy (97010), and the physical medicine procedure (97139) provided on October 6, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the maxillofacial area for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary and beneficial to the enrollee's health.The Plandenied your request. The Plansaysthatthe clinical information provided does not meet the criteria.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 scan.Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has sphenoid disease and mastoiditis on the side she has headaches and facial pain. She was first treated with medical treatment which was PO antibiotics. It would be within standard of care to perform a follow-up image, such as CT, after completing her course of antibiotics. The CT scan is both medically indicated and necessary for this enrollee. Sphenoid disease that does not respondto antibiotics and continues to cause symptoms would possibly warrant surgical intervention.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the maxillofacial area for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen 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 laboratory services provided on October 7, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 laboratory 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 laboratory services provided on October 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission 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 above 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 the enrollee received oral medications and insulin. The enrollee has stable vital signs. The enrollee required stand-by assistance/supervision to contact guard assistance with functional mobility. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medicallynecessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home oxygen (E1392).
You asked the Plan to pre-approve the home oxygen. You say that the oxygen is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 home oxygen. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found the provided records did not clearly show support for home oxygen use. There was no record of low oxygen or failure of other treatments to help meet criteria. 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 home oxygen have not been met. Therefore, we decided that the Plan does not have to pre-approve home oxygen (E1392).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGemzar.You asked the Plan to pre-approveGemzar. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Gemzar. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has squamous cell carcinoma (SCC) of the scalp. The documentation does not support that the requesteddrug is FDA-approved for the enrollee's diagnosis. The documentation does not show that the requested use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gemzar have not been met.Therefore, we decided that the Plan does not have to pre-approveGemzar
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formolecular pathology testing provided to the enrollee on September 10, 2020.
You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says if the laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.The Planmust 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 wascorrect in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition.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 testing have not been met.Therefore, we decided that the Plan does not have to pay formolecular pathology testing provided to the enrollee on September 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services (A0428) provided on February 21, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that the enrollee was billed out of network for the transportation the hospital pre-arranged.The Plan denied your request. The Plan says you were charged this cost sharing 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). The enrollee'scontract with the Plan clearly says that enrollees must pay a $230 copayment for each ambulance trip. The enrollee had 1 ambulance trip. The Plan charged the enrollee $230 for these services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance services (A0428) provided on February 21, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor for the enrollee.You asked the Planto pre-approvethe monitor. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of medical necessity.
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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no need for frequent medication changes. The monitor would not be considered therapeutic.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 monitor have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit and collar bone x-ray provided on December 3, 2019.
You asked the Plan to pay for the outpatient office visit and collar bone x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says this provider opted out of Medicare on May 16, 2013.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 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. Therefore, we decided that the Plan does not have to pay for the outpatient office visit and collar bone x-ray provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion services received on September 23, 2020.
You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the paring or cutting of benign hyperkeratotic lesion services have not been met. Therefore, we decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion services received on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional home glucose monitor test strips.You asked the Planto pre-approvethe additional strips. You say that this is medically necessary.The Plandenied your request. The Plansaysno reason is given for testing more than once daily.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 additional strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no rationale for why you need to check more than one time a day. There is no documentation if you are on a medication that can cause low blood glucose readings.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 additional strips have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional home glucose monitor test strips
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicarerules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect 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. Our physician reviewer found you were admitted for weakness associatedwith COVID 19 infection. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met at a lower level of 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 havenot been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided. on September 23, 2020.You asked the Plan to waive the coinsurance for medical supplies. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.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 20% coinsurance for prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed amount is $192.60. The total amount you are being asked to pay is $38.52 ($192.60 x 20% = $38.52). Medical supplies fall within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based onyour 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 medical supplies provided by a participating provider on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on October 26, 2020.

You asked the Plan to waive the copayment for an office visit. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $5 copayment for physician/practitioner services/PCP. 

You have been asked to pay a $5 copayment for an office visit. The correct copayment has been applied to the office visit that was provided. An office visit falls within the physician/practitioner services/PCP 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 office visit provided by a participating provider on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on June 5, 2020.You asked the Plan to waive the copayment for lab work. You say that you were never told that you would owe for lab work. The Plan denied your request. The Plan says the correct copayment has been applied.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 $10 copayment for outpatient diagnostic tests/in-network/lab work. You have been asked to pay a $10 copayment for lab work. Lab work falls within the outpatient diagnostic tests/in-network/lab work 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 lab work provided by a participating provider on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level oncology referral.

You asked the Plan to pre-approve the referral. You say that this is needed to treat acute my eloid leukemia.The Plan denied your request. The Plan says this level of service is available in plan.

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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you can be managed by an in-network provider. 
If there is a failed venetoclax regimen, you can receive low dose ARA C with an in-network provider.

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 referral have not been met.Therefore, we decided that the Plan does not have to pre-approve a tertiary-level oncology referral
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRocklatan ophthalmic solution.You asked the Plan to pre-approveRocklatan ophthalmic solution. You say that the enrollee has tried and failed alternative medications.The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.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 pre-approveRocklatan ophthalmic solution.Benefits for Rocklatan ophthalmic solutionmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.