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

We decided that the Plan has to pre-approve a special injection to the spine.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no appropriate follow-up re-evaluation to determine if the enrollee would need additional procedures.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 injection. Our reviewer says that the requested injection is considered medically reasonable and necessary in this case. Our physician reviewer found you achieved a positive diagnostic facet block. You also have the indications for an epidural steroid injection - facet joint pain, chronic low back pain, and degenerative disc disease. The procedure is medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-approve a special injection to the spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on October 15, 2019.You asked the Plan to pay forthe services. You say that since the enrollee's hospice was revoked the claim should be payable by the Plan.The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The member was enrolled with hospice from June 20, 2019 through July 27, 2019 and August 2, 2019 through October 3, 2019.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on April 4, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that the patient failed to provide you with the correct insurance. You say that excellent care was provided and reimbursement is being requested.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 has network providers available who can provide 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 foran office visit provided on April 4, 2019 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the cleaning (D1110), and the intraoral x-rays (D0210) provided on October 8, 2019. You asked the Plan to pay for the comprehensive oral evaluations (D0150), the cleaning (D1110), and the intraoral x-rays (D0210). You say that you were told by the dental office that your claim would be paid directly to you. The Plan denied your request. The Plan says the services are denied because the dentist is an out-of-network provider. 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. Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the cleaning (D1110), and the intraoral x-rays (D0210) provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording (CPT Code 95250) provided tothe enrollee on August 7, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Current Procedural Terminology (CPT) code 95250 (1 unit) remains not supported. The documentation submitted do not indicate that ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording was performed; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording (CPT Code 95250) provided to the enrollee on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network gynecology visit on November 22, 2019.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says this benefit is covered every 24 months and was exhausted at the time of service. The Plan states your records show you previously received this service on November 154, 2018, which is less than a 24-month period between exams.
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 PAP smears and pelvic exams are covered every 24 months. This benefit was not available at the time of service. Therefore, we decided that the Plan does not have to pay for an out of network gynecology visit on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PMD (CPT Code K0862) and accessories, for the enrollee.
You asked the Plan to pre-approve the PMD. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the enrollee already has a PMD.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PMD have not been met. The enrollee currently has a PMD. The information we received does not state why it needs to be replaced at this time. The enrollee is considering spinal surgery in the future. It is not clear how this surgery may impact the enrollee's functional abilities such as walking. We cannot determine what features the enrollee may require on a PWD. We can only approve items that the enrollee needs. Please work with the enrollee's care team to have a new evaluation post-surgery. Therefore, we decided that the Plan does not have to pre-approve the PMD (CPT Code K0862) and accessories, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine HC1.
You asked the Plan to pre-approve this drug. You say that this is the only allergy pill that works for you. The Plan denied your request. The Plan says that this medication is not covered under 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-approve Hydroxyzine HC1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on October 17, 2019. You asked the Plan to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays. You say that you have always used in-network providers while having this insurance. You also say that you had no idea that this provider was not in-network with your plan. The Plan denied your request. The Plan says these services 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat transthoracic echocardiogram for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says it is suggested that there is a follow-up with the doctor for the next step in care.
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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, the enrollee had a cryptogenic stroke and a good quality transesophageal echocardiogram that did not reveal/report any evidence of atrial septal abnormality or patent foramen ovale. In this circumstance, a good quality transesophageal echocardiogram is documented and is more accurate than transthoracic echocardiography for evaluation of a patient foramen ovale. Therefore, the records do not support the medical necessity for an additional transthoracic evaluation to assess for a patent foramen ovale. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat transthoracic echocardiogram for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchoscopy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a tracheoesophageal fistula.
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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the he enrollee was to undergo a simple exchange of an established tracheotomy; a procedure which can be done at the bedside. There is no evidence that the enrollee was experiencing respiratory issues/complications. Therefore, there is no documentation to support the provision of a bronchoscopy to exchange the tracheotomy. The billed procedures are not shown to have been medically necessary or 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchoscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay $84 for chiropractic services provided on November 27, 2019.
You asked the Plan to pay $84 for this service. You say that this office visit should be covered by the Plan. The Plan denied your request. The Plan says the services provided are not covered under the Plan contract.
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 $84 for chiropractic services provided on November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest (71250).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 CT scan. Our reviewer says that the CT scan is not indicated at this time. Our physician reviewer found the enrollee is noted to have pulmonary fibrosis, which on her August 2019 evaluation was stable and only mildly symptomatic. There is no evidence of new or worsening signs or symptoms. There is no evidence of recent changes on a CXR. Therefore, the requested CT scan of the chest is not shown to be currently medically necessary or 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest (71250).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care (99305) provided by out of network (OON) provider on November 11, 2019.
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 that the 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 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. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care (99305) provided by the out of network (OON) provider on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
You asked the Plan to pre-approve the manual wheelchair. You say that you would like reconsideration because you are unable to stand and hit your head. The Plan denied your request. The Plan says your doctor did not submit notes that state how you currently walk, why you cannot use a walker or cane and what activities you cannot complete without the wheelchair.
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 manual wheelchair. Our reviewer says that there is no documentation of the member's mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. Our physician reviewer found also missing in the documentation is information regarding if the member has a mobility limitation and whether or not their mobility limitation can or cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. There is no wheel chair evaluation to assess if their home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair if provided.
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 manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from September 16, 2019 to October 14, 2019. You asked the Plan to pay for out of network services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan contract says that podiatry services may require prior authorization. This provider is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided from September 16, 2019 to October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for a laparoscopy (43644).
You asked the Plan to pre-approve the laparoscopy. You say that you are requesting this service for the treatment of your condition, not weight loss. The Plan denied your request. The Plan says the records do not show any indications for surgery.
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 laparoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not cover bariatric surgery for BMI <35 kg/m2 and failure at weight loss efforts. There are no documented efforts regarding dietary control. Bariatric surgery is not indicated as standard treatment for gastroparesis. There are non-surgical treatments for gastroparesis including endoscopic treatments that may be less risky and with less morbidity. 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 laparoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for a laparoscopy (43644).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 360 electrodes (A4595) per month for the enrollee. You asked the Plan to pre-approve 360 electrodes per month. The Plan denied your request. The Plan says that they do not see why the extra electrodes are needed. 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 360 electrodes per month. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The medical records provided do not provide documentation as to why it is medically reasonable and necessary for the enrollee to have more of the A4595 TENS unit electrodes than allowed by the Local Coverage Determination. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the electrodes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 360 electrodes per month have not been met. Therefore, we decided that the Plan does not have to pre-approve 360 electrodes (A4595) per month for the enrollee.