Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
You asked the Plan to pre-approve the SSBCI benefit. You say that you need to be re-evaluated for eligibility of the SSBCI benefit. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefit for the Chronically Ill for 2021.
Medicare generally does not cover supplemental benefits. However, the Plan offers a special supplemental benefit for the chronically ill (SSBCI) that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SSBCI benefit have not been met. Specifically, the record does not show that you have been diagnosed with any of the qualifying diagnoses. Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Vertiflex procedure (22869) performed on January 6, 2021.
You asked the Plan to pay for a Vertiflex procedure. You say that the procedure at issue is recognized by Medicare. The Plan denied your request. The Plan says the procedure at issue is experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the procedure at issue is not part of clinical practice guidelines and is considered still experimental/investigational. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pay for a Vertiflex procedure (22869) performed on January 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97164) provided January 26, 2021.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 97164 is not supported in the medical record. Specifically, the records show the services were provided in the home setting. There is a more appropriate CPT code to describe these services in this setting (G0151). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97164) provided January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper extremity prosthesis (L7499) to be provided by an out of network provider.
You asked the Plan to pre-approve an upper extremity prosthesis. You say that the requested item can improve the enrollee's hand function. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 item at issue in this appeal. We found no exception that would require the Plan
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an upper extremity prosthesis (L7499) to be provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 4, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not include a valid written order.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Specifically, the documentation does not include a valid
physician order. The Plan has indicated that the signing provider alleges that they did not sign this order. Therefore, we decided that the Plan does not have to pay for genetic testing provided on November 4, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the chest.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the guidelines support a recent chest x-ray as the initial imaging study prior to considering advanced imaging of the chest.
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 severe COPD, with increased cough and sputum production over the past 1.5 years. The plan has denied this scan because there has been no recent chest x-ray. However, a negative chest x-ray does not rule out significant bronchiectasis, and would not prevent the need for a chest CT scan in this situation. 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 Plan has to pre-approve a CT scan of the chest.
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gammagard Liquid.
You asked the Plan to pre-approve the Gammagard Liquid. You say that you would like reconsideration
because the requested drug is medically necessary. The Plan denied your request. The Plan says that the
accepted use of this drug for the member's illness requires they are experiencing acute myasthenic crisis with
decompensation (respiratory failure or disabling weakness).
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 Gammagard Liquid. Our reviewer
says that this service would meet/satisfy the requirements for classification of being reasonable and necessary.
Our physician reviewer found based off the letter from the treating provider, the use of steroids would not
readily be an option given the diabetes. The use of intravenous immunoglobulin in the setting of a marrow
disorder would also preclude the use of an immunosuppressive agent.
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 Gammagard Liquid have been met. Therefore, we decided that the Plan has
to pre-approve Gammagard Liquid.
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 the outpatient office visit (99203) extraspinal manipulative treatment (98943) electrical stimulation (97014) hot/cold packs (97010) massage therapy (97124) provided January 13, 2021 to February 25, 2021.
You asked the Plan to pay for the chiropractic services. You say that you are appealing for reconsideration of coverage in full for services provided for treatment of severe back pain. You were in terrible pain and needed help. The Plan denied your request. The Plan says these services are not covered. The plan had approved procedure codes 98942 and 98941 with the applicable $20 copayments.
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 the outpatient office visit (99203) extraspinal manipulative treatment (98943)
electrical stimulation (97014) hot/cold packs (97010) massage therapy (97124) provided January 13, 2021 to February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on February 12, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $40 copayment for a specialist office visit. You have been asked to pay a $40 copayment for the specialist office visit provided. 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 office visit (99213) provided on
February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided in Mexico from July 8, 2020, through July 26, 2020.
You asked the Plan to pay for the physician's services. You say that the Plan's negligence in failing to diagnose your wife's cancer in December 2019 caused her to lose two months of treatment that may have prolonged her life. The Plan denied your request. The Plan says the Health Plan and Medicare rules require the member to obtain covered services, except for emergency care and out-of-area unforeseen urgent care, from Plan providers. The routine services provided to the member by the non-Plan provider are not covered because they were not authorized by the Plan, not emergent, and not urgently needed while the member was outside the Plan's service area.
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. The services provided were not due to unforeseen illness or condition. 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 in Mexico from July 8, 2020, through July 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services (90960) provided on January 30, 2021, by an out of network (OON) provider.
You asked the Plan to pay for dialysis services. You say that you were not aware the enrollee was enrolled in a Managed care plan. The Plan denied your request. The Plan says prior authorization was not obtained 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 dialysis services (90960) provided on January 30, 2021, by an out of network (OON) provider.
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 an LTACH is medically necessary for
this enrollee. The Plan denied your request. The Plan says there are no complicated wounds or multiple
complicated medications which cannot be given in the current location. An 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 LTACH care is not considered medically reasonable and necessary in this case. 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 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 LTACH services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 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 care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does have documented skilled nursing needs, requiring wound care and positioning. The enrollee does have documented skilled therapy needs, requiring strength and transfer training. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point cannot be provided at a lower level of care. While the enrollee may plateau quickly, a trial of skilled therapy is reasonable. 

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the patient would benefit from continued therapies at a subacute facility as the patient is unable to handle current level of therapies required on the inpatient rehabilitation unit. The Plan denied your request. The Plan says that the patient does not appear to be medically stable for transition to a lower level of care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 9, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you should not have been billed a copayment since it was part of an annual physical. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 other laboratory tests that are not a fecal immunochemical test (FIT), for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that if you receive services during an annual physical exam that address a medical condition, during the same office visit, additional cost-shares may apply. You have been asked to pay a $10 copayment for laboratory services. The EOC confirms that $10 is the required copayment for this service. The EOC also confirms that you pay $10 per day for laboratory tests that are not a FIT test. Laboratory services fall 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 thyroid stimulating hormone test (84443) provided on February 9, 2021.
Appeal type: Lab
Decision: Partially Favorable

You asked the Plan to pay for genetic testing. You say that this testing clearly met the coverage criteria, and you are the sole proprietor of these tests The Plan says that the denial of payment for this testing is correct, because these tests do not meet the criteria for coverage.
We decided that the Plan has to pay for pharmacogenomic testing.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that the pharmacogenomic testing would not be covered. Under Medicare rules, this means pharmacogenomic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for pharmacogenomic testing.
We also decided that the Plan does not have to pay for MTHFR testing.
The Plan follows Medicare rules. Medicare rules state that MTHFR testing is considered investigational and is not a Medicare covered benefit.
This MTHFR testing is explicitly excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for MTHFR testing.
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 the pathology examination of tissue using a microscope (88305) provided on July 9, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the pathology examination of tissue using a microscope. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 the pathology examination of tissue using a microscope (88305) provided on July 9, 2020, by an out of network (OON) provider.