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

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 6, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you did not have to pay this much when you had this done is 2019. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because therapy is
necessary for the member to be able to move their arm. The Plan denied your request. The Plan says the
member's care can be provided at home with home healthcare.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical pathology services provided .You asked the Plan to pay forthe surgical pathology 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 topay 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 surgical pathology services. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forsurgical pathology services provided .
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of pegfilgrastim.You asked the Plan to pre-approvepegfilgrastim. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this request can only be approved in the enrollee experienceshospitalization for febrile neutropenia or delay or dose reduction for neutropenia.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve pegfilgrastim. Our reviewer says thatthe enrollee does not meet the criteria for the requested use of pegfilgrastim. Our physician reviewer found the requested use of pegfilgrastim is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by research that appears in a Medicare-approved medical journal.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pegfilgrastim have not been met. Therefore, we decided that the Plan does not have to pre-approveuse of pegfilgrastim.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0651) and accessory (E0667).You asked the Plan to pre-approvea pneumatic compression device and accessory. You say that you need this device to treat your swelling.The Plan denied your request. The Plan says the records do not show that you have failed conservative therapy.The Plan must follow Medicare rules. Medicare rules say a four-week trial of conservative therapy demonstrating failed response to treatment is requiredfor coverage of a pneumatic compression device. We looked at the file and Medicare rules. The submitted medical records do not included documentation of conservative therapy. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device and accessory have not been met.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0651) and accessory (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe genicular nerve block of knee.You asked the Plan to pre-approvethe genicular nerve block. You say that you would like reconsideration because the member had the same service approved in 2019.The Plan denied your request. The Plan says there is insufficient evidence to support the use of genicular nerve blocks in the treatment of pain caused by degenerative diseases.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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental and is the subject of ongoing clinical trials.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 genicular nerve block have not been met.Therefore, we decided that the Plan does not have to pre-approvethe genicular nerve block of knee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided by an out of network (OON) provider.

You asked the Plan to pay for the physician service. You say that the claim was denied for "no authorization." You also say that the services provided to the enrollee were medically necessary. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered. The Plan says it is the provider's responsibility to verify the enrollee's current eligibility and authorization requirements prior to the services being rendered to the enrollee.

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 domiciliary visit provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on October 23, 2020.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these charges. You also say that you should not have to pay for it. The Plan denied your request. The Plan says that there is a $1,000 maximum allowance for dental services. The Plan says that the maximum allowance has been exhausted.
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. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. The record shows that the Plan has only paid $1,000 out of the $2,000 allowance that is stated in the Evidence of Coverage.
Date of Service
Plan Paid
2/12/2020
$345
2/17/2020
$237
2/25/2020
$418
TOTAL:
$1,000
Therefore, we decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on October 23, 2020.
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 Subsequent nursing facility care (99310) provided on September 16, 2020, by an out of network (OON) provider. You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained and OON criteria were not met for the 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 the Subsequent nursing facility care (99310) provided on September 16, 2020, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient infusion services (96360, 96361, G0463) provided  by an out of network (OON) provider.You asked the Plan to pay forthe infusion services. You say that you inadvertently did not obtain prior authorization, but the services were medically necessary.The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The services were not pre-approved or urgent. This care could have been provided in network.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 forthe outpatient infusion services (96360, 96361, G0463) provided  by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74176). 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 that coverage criteria has not been 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 medically necessary. Our physician reviewer found the plan's review indicates that they applied criteria for an enrollee without a cancer history. The case file indicates that the enrollee had stage 1 ovarian cancer in 1987 treated with surgery. The requested CT scan is consistent with standards of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74176). 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lightweight wheelchair (K0003).
You asked the Plan to pre-approve the lightweight wheelchair. You say that you would like reconsideration because the member uses a cane and is not steady enough to walk. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the lightweight wheelchair.
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair for use inside the home is covered if the member meets specific criteria. 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 lightweight wheelchair. Our reviewer says that there is no documentation in the available records that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. There is no documentation in the available records that the enrollee has sufficient upper extremity function needed to safely self-propel the manual wheelchair that is provided in the home during a typical day or that the enrollee has a caregiver who is available, willing, and able to provide assistance with the wheelchair. Our physician reviewer found there is no documentation that the enrollee cannot self-propel in a standard wheelchair in the home. 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 lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the lightweight wheelchair (K0003).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 an outpatient surgery provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided to you.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided to you.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) provided on April 15, 2020.
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for payment have not been met.
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 knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was diabetes. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is no objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitoring device (CGM) (K0553, K0554). You asked the Plan to preapprove the CGM. You say that the enrollee has failed traditional monitoring. The Plan denied your request. The Plan says the enrollee does not meet Medicare coverage criteria. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitoring device (CGM) (K0553, K0554).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50-mile limit for routine transportation for the enrollee.You asked the Plan to pre-approveexceptions to supplemental benefits. You say that you need this transportation to get to your doctor's appointment.The Plan denied your request. The Plan says that your request exceeds the benefit limit.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50-mile limit for routine transportation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing (U0003) provided on July 24, 2020. You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in Illinois while the member and laboratory are located in Texas. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing (U0003) provided on July 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services (A0427 and A0425) provided .You asked the Plan to pay forthe ambulance services. You say that you would like reconsideration becausethe ambulance services were medically necessary.The Plan denied your request. The Plan says this service is not covered by Medicare.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 the ambulance services. Our reviewer says that the presenting complaint of urinary retention would not meet prudent layperson criteria for emergency care. Other transportation methods such as wheelchair van or stretcher van would not have been contraindicated for you. Our physician reviewer found the documentation does not suggest you required any expertise or special equipment during transportation.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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services (A0427 and A0425) provided