Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for wound debridement provided on September 10, 2019.
You asked the Plan to waive the copayment for wound debridement. You say that you disagree with the surgical charges because services were provided by your primary care provider. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for surgery services furnished in a primary care providers office. The record shows that you received wound debridement on September 10, 2019. The provider is listed as a rural clinic, not an outpatient hospital facility. Therefore, you cannot be charged a copayment for outpatient hospital facility services. The Plan says you must pay a $169.66 copayment for wound debridement. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for primary care provider visits. Therefore, we decided that the Plan has to waive the copayment for wound debridement provided on September 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.You asked the Plan to pre-approve the Repatha Sureclick. The Plan denied your request. The Plan says Repatha Sureclick is intended for self-administration, which is not a drug covered under the enrollee's Part B plan.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 Repatha Sureclick.Benefits for the Repatha Sureclickmay 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to providenon-emergency transportation; mileage, per mile.You asked the Plan to providethe non-emergency transportation. You say that you want to continue to see your neurologist, but the provider is over the plans benefit distance.The Plan denied your request. The Plan says they are not required to provide transportation to your specialty provider that is more than 60 miles from your home.Medicare does not covertransport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of the non-emergency transportation have not been met.the provider that you were seeing . There are multiple neurologists within the 60 mile radius of your home that you can see.Therefore, we decided that the Plan does not have to providenon-emergency transportation; mileage, per mile.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the therapists are recommending a lower level of care, such as skilled nursing facility.The Plan must follow Medicare rules. 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 was correct 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The enrollee may benefit from additional multiple therapies, however the patient's current medical status with episodes of desaturation, continued need for BIPAP, generalized pain do not indicate that the enrollee requires, can tolerate and fully participate in an IRF level rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on December 30, 2019.You asked the Plan to waive the copayment for wound debridement. You say that the services are needed. You say that this provider has been paid in the past.The Plan denied your request. The Plan says you are only responsible for the $65 copayment.The rules say a planmust 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 $65 copayment for surgery services at an out-of-network specialist's office. You have been asked to pay a $65 copayment for wound debridement. Wound debridement falls within the "Physician/Practitioner services, including doctor's office visits" 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 wound debridement provided on December 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450) provided on November 22, 2019.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary and billed correctly. The Plan denied your request. The Plan says the claim is a duplicate of another claim.
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 70450 is not supported in the medical record. Specifically, the record shows the claim is a duplicate of a claim that was already processed. Correct coding and/or modifiers were not applied to denote a repeat service. 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 pay for Computed Tomography (CT) of the head (70450) provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 16, 2019, December 23, 2019 and December 30, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on December 16, 2019, December 23, 2019 and December 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the air ambulance service provided on February 13, 2019.
You asked the Plan to reimburse you for the air ambulance transport. You say that it was medically necessary to be air ambulance transported home. The Plan denied your request. The Plan says return trips home from a foreign hospital are not covered by Medicare or the Plan.
The Plan follows Medicare rules. The rules say that return trips from a foreign country are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance transport have not been met. Therefore, we decided that the Plan does not have to reimburse you for the air ambulance service provided on February 13, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Vectra DA genetic testing
You asked the Plan to pay for Vectra DA test. You say that this test was ordered by the enrollee's physician to determine the most beneficial treatment for the enrollee, so you are requesting payment. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with the Plan and this test is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say that Vectra DA testing is covered by Medicare. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan. The Plan did not provide documentation of prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care. Furthermore, the Plan has denied payment on the basis that Vectra DA testing is not covered by Medicare. According to Medicare rules, Vectra DA testing is covered by Medicare up to 2 tests per patient per year. The record does not show that this testing exceeded Medicare's benefit limit of 2 tests per patient per year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to upper extremity prosthesis, prefabricated glove for terminal device (L6890 x3) electronic elbow sequential (L7180) automatic grasp feature (L6881).You asked the Plan to pre-approve parts for approved prosthesis. You say that please review the attached medical documentation. A mio electric system requires no excursion  or cable pulling of any kind and is the best, most appropriate option for the enrollee.The Plan denied your request. The Plan says The plan approved two gloves. More than two gloves are not medically necessary. The parts requested for the hand and elbow are already included with the approved prosthesis.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 parts for approved prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for the L6890 x 3 exceeds the enrollee's medical need and is therefore not medically necessary. The requested L7180 electronic elbow appears to have a powerful Bluetooth module, which permits secure configuration via a computer. This blue tooth technology is not furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member and exceeds the enrollee's medical needs. Furthermore, the requested elbow is not authorized for the type of prosthetic device requested. The automatic grasp feature L6881 x 1 exceeds the enrollee's medical need and is not considered within the standards of medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a malformed body member.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of parts for approved prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approve addition to upper extremity prosthesis, prefabricated glove for terminal device (L6890 x3) electronic elbow sequential (L7180) automatic grasp feature (L6881).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for advanced care planning (ACP) (99497) provided on September 5, 2019.
You asked the Plan to pay for advanced care planning. You say that Medicare rules state this is a covered service. The Plan denied your request. The Plan says that the member received an annual wellness visit less than 12 months prior to this service, so both the AWV and ACP cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that if an AWV is denied for exceeding the once-per-year limit, Medicare can still make the ACP payment. We looked at the file and Medicare rules. Although the annual wellness visit was denied based on frequency limitations, Medicare rules state that advance care planning can still be paid. Based on this information, we decided that Medicare rules for coverage of advanced care planning have been met. Therefore, we decided that the Plan has to pay for advanced care planning (ACP) (99497) provided on September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the services provided on July 27, 2019. You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that the provider is out-of-network. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not justify why they would not pay for the services. Therefore, we decided that the Plan has to pay for the services provided on July 27, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient services provided by Out of Netwrok (OON) provider from October 18, 2019 to October 19, 2019.You asked the Plan to pay for the inpatient services. You say that your provider expressed concern for your health during the surgery. The Plan denied your request. The Plan says that the clinical information does not support the medical necessity of the admission.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. Heritage Health follows these rules.You were referred for the inpatient services by Out of Netwrok (OON) provider. Out of Netwrok (OON) provider is a contract provider. The file does not show that plan provided notice that the inpatient services would not be covered. Under Medicare rules, this means the inpatient services is considered approved by Heritage Health.Therefore, we decided that the Plan has to pay for inpatient services provided by Out of Netwrok (OON) provider from October 18, 2019 to October 19, 2019.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: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 code S9366 is home infusion therapy, total parenteral nutrition (tpn); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard tpn formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem. We find that CPT code S9366 is not supported in the medical record. Specifically, code S9366 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) services.
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is needed to assess for underlying malignancy and for a possible biopsy. The Plan denied your request. The Plan says that the records do not show that the enrollee's lung nodule is eight millimeters or larger on any previous advanced imaging of the chest.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the criteria for coverage has been met. Our physician reviewer found the enrollee has a significant smoking history, and a recent pneumonia. The CT scan of the chest raised suspicions about a LUL mass obstructing the bronchus and causing a post obstructive pneumonia. This is the reason for the PET scan. There is also a 6 mm nodule, which could be a metastatic lesion. This nodule is not the main reason for the PET scan. A PET/CT is reasonable and medically necessary to help establish staging of the suspected primary lung carcinoma. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) services.
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: Favorable

We decided that the Plan has to pre-approve a percutaneous left atrial closure
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the documentation does not show the enrollee cannot take blood thinner medication.
The Plan follows Medicare rules. Medicare rules say that a percutaneous left atrial closure is only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has chronic atrial fibrillation, with a CHA2DS2-VASc score of 3. He has a complex medical history with dialysis dependent renal failure, calciphylaxis, diffuse calcification, and skin wounds secondary to this syndrome. He recently needed to discontinue his chronic warfarin therapy due to both its association with calciphylaxis and the ongoing bleeding from these wounds, which worsened his baseline anemia from his CKD. He had a parathyroidectomy to try to halt the calciphylaxis, but this therapy is often of only limited value in the treatment of this illness and he remains at risk for recurrent complications and recurrent severe skin wounds from calciphylaxis. He is therefore not a good candidate for long-term anticoagulant therapy required for his AF despite tolerating lower dose apixaban at present. Given the complexity of the clinical situation, he does have a significant contraindication to long-term anti-coagulation. Consideration of a Watchman device is both reasonable and necessary in this enrollee as he meets the multiple criteria. There is also additional documentation that there was shared decision making, a non-interventional cardiologist was involved and the procedure will be performed by a qualified physician in a qualified center. The enrollee will also remain in the registry trial post procedure. Therefore, the criteria for the requested services have been met.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out of network (OON) provider.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 rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 January 6, 2020 by an out of network (OON) provider.