Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on November 1, 2019.
You asked the Plan to waive the copayment for an x-ray provided on November 1, 2019.. You say that your copayment should be only $10. The Plan denied your request. The Plan says this service processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for x-ray services provided by a specialist in an outpatient hospital. You have been asked to pay a $59.57 copayment for an x-ray provided on November 1, 2019. This is less than the $100 copayment listed in your evidence of coverage. 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 x-ray provided on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the C-reactive protein testing rendered to you on September 10, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that C-reactive protein testing is covered when specific criteria are met.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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the records show that you are at high risk for recurrent heart complications. The treatment plan would not be changed by the outcome of the testing at issue. You do not meet the criteria for coverage and the testing was not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pay for the C-reactive protein testing rendered to you on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy provided by a chiropractor from December 12, 2018 to December 26, 2018.
You asked the Plan to pay for manual therapy. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
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 manual therapy provided by a chiropractor from December 12, 2018 to December 26, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 11, 2019.
You asked the Plan to pay for the services. You say that the services were provided to avoid delay in care. The Plan denied your request. The Plan says the services were not authorized.
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 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 medical services provided to the enrollee by an out-of-network provider on July 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The Plan denied your request. The Plan says the requested Euflexxa is not medically necessary.
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 Euflexxa. Our reviewer says that the requested Euflexxa is not medically necessary. Our physician reviewer found the enrollee is with a history of chronic knee and lower back pain. The medical records do not show adequate conservative measures for knee pain. There has not been sufficient medical therapy including medications for knee pain. The records do not show that the enrollee has had adequate medications for degenerative joint disease treatment. Euflexxa also is not recommended by the American Academy of Orthopedic Surgeons for use in patients with knee degenerative joint disease. Euflexxa is not medically necessary in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 additional outpatient physical therapy visits.
You asked the Plan to pre-approve the 11 additional outpatient physical therapy visits. The Plan denied your request. The Plan says 11 additional visits are not medically reasonable or necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the outpatient physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment or that the services can be safely and effectively performed only by a therapist. The enrollee has made improvements with the previous 19 outpatient physical therapy visits and has been instructed on a home program. The records do not support continued therapy is medically 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 outpatient physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 11 additional outpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August7, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 Plandid not pre-approve the servicesat 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 physician's services providedon August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bathroom lift.
You asked the Plan to pre-approve bathroom lift. You say that the enrollee lives alone and needs this device to assist her in daily living. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this device is not primarily medical in nature and is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a bathroom lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour Next Test Strip for the enrollee.
You asked the Plan to pre-approve the strip. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation as to why the preferred meter can't be used.
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 strip. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no rationale for the use of the non-preferred brand. There is no specific medical
necessity for this brand.
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 strip have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Contour Next Test Strip for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study for the enrollee.
You asked the Plan to pre-approve a sleep study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sleep studies are only covered for certain 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 a sleep study. Our reviewer says that the documentation does not support that the requested sleep study is medically reasonable or necessary. Our physician reviewer found the enrollee has risks for sleep apnea. An in-lab sleep study can be considered when a Home sleep study has been attempted and is negative, inconclusive, or technically inadequate (report submitted for review). An in lab sleep study can be considered when a home sleep study cannot be done due to one of the following reasons: obstructive sleep apnea symptoms with low pretest probability of obstructive sleep apnea or the patient does not have the mobility, dexterity or cognitive ability to use the available equipment safely at home and the ability to follow instructions. The documentation supports that the enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of a sleep study. 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram services provided on January 28, 2019 by an out of network provider.
You asked the Plan to pay for the electrocardiogram services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 for the electrocardiogram services provided on January 28, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not have to pay for drug testing services provided to the enrollee on September 9, 2019.You asked the Plantopay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe submitted lab order is signed for 9/10/19, not 9/9/19.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code80307 is "Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service."We find that CPT code 80307 is not supported in the medical record. Specifically, the lab order is signed and dated on 9/10/19, which is not the correct date of service. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revlimid capsules.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee is on maintenance therapy
with this drug and needs to continue. The Plan denied your request. The Plan says the denial of authorization
for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer
the enrollee's Medicare Part D prescription drug benefits.
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 Revlimid capsules.
Benefits for self-administered drugs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough evidence to support the use of bone marrow aspiration.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on July 5, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says out-of-network services are not covered.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 services at issue in thisappeal. 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 forthe medical services provided to you by an out-of-network provider on July 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 12, 2019 by out of network provider.
You asked the Plan to pay for physician visit. You say that the nursing home is responsible for obtaining prior authorization for patients, and you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 for the medical services provided on July 12, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy rendered to you at an outpatient hospital on August 22, 2019.
You asked the Plan to waive the copayment for these services. You say that you do not know why the procedure was billed as diagnostic. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for same day outpatient surgery at an outpatient hospital.
Review of the file shows that you received a diagnostic colonoscopy at an outpatient hospital on August 22, 2019. The records show that the colonoscopy was diagnostic in nature and not screening because it was performed for a diagnosis of ulcerative colitis. You have been asked to pay a $400 copayment for these services. These services fall within the same day outpatient surgery at an outpatient hospital 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 the colonoscopy rendered to you at an outpatient hospital on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided on July 31, 2019 and August 12, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider submitted an affidavit to Medicare expressing their decision to opt-out of the program.
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. The rendering provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit services provided on July 31, 2019 and August 12, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven further home health physical therapy (PT) visits for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says four visits are approved but seven further are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation is conflicting on the enrollee's functional status. The documentation from the physician dated November 7, 2019 notes a normal functional status, strength, joint range of motion, and normal ambulation. There are no coordination issues that are significantly different findings from the therapy note dated November 26, 2019. Seven further PT visits are not supported by the records and are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve seven further home health physical therapy (PT) visits for the enrollee.