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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable with no skilled needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 25, 2019 through March 27, 2019.You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based onthe records submitted. The Plan denied your request. The Plan says the member has veteran status and Medicare doesn't cover services from Veteran Affairs hospitals, medical centers or administration hospitals.The Plan must follow Medicare rules. Medicare rules say that an authorization issued by the Veterans' Administration (VA) binds the VA to pay in full for the items and services provided. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, payment may not be made for items or services furnished by a provider or other person at public expense pursuant to an authorization issued by a Federal agency, furnished by a provider of services or agency of the Federal government, or paid for directly or indirectly by a Federal, State, or local governmental entity. Therefore, we decided that the Plan does not have to pay for outpatient services provided on January 25, 2019 through March 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the breast biopsy or the placement of breast localization device procedure provided on August 14, 2019 and September 5, 2019.You asked the Plan to reduce the copayments forthe breast biopsy and the breast procedure. You say that you do not believe the services count as surgery because the provider referred to them as "procedures" on the phone. You say you should be charged a $25 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $200 copayment for the breast biopsy and a $200 copayment for the breast procedure. The breast biopsy and breast procedure fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that these two procedures are considered surgical procedures.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, wedecided that the Plan does not have to reduce the copayments forthe breast biopsy or the placement of breast localization device procedure provided on August 14, 2019 and September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor and Reader.
You asked the Plan to pre-approve a Freestyle Libre Sensor and Reader. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Medicare guidelines say that in order for a therapeutic CGM to be covered, all of the above criteria must be met. Medicare says the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump in order to be covered. In this case, the file shows that you are not insulin-treated. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Sensor and Reader havenot been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre Sensor and Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea genicular nerve block.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis of the knee. The requested genicular nerve block is considered experimental/investigational in nature and is not reasonable or medically necessary at this time.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-approvea genicular nerve block.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on August 9 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on August 9 2019.
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 care can be received in another setting.
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. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97162, 97140, and 97530) provided on June 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy services. You say that these services were not authorized because the case was handled by a new employee. The Plan denied your request. The Plan says services from out-of-network providers require 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 physical therapy services (97162, 97140, and 97530) provided on June 6, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brimonidine 0.2% eye drop.You asked the Plan to pre-approve Brimonidine 0.2% eye drop. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveBrimonidine 0.2% eye drop.Benefits for Brimonidine 0.2% eye dropmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network consultation services. You say that you need a consultation because you are receiving dialysis and need a catheter. You say that the physician was recommended as a great doctor. The Plan denied your request. The Plan says the physician is not a participating provider with the Health Plan. The Plan says that there are in-network providers who can supply you with a second opinion.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 out-of-network consultation services. Our reviewer says that Our physician reviewer found 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 out-of-network consultation services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the out-of-network consultation services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided August 20, 2019.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary and correctly billed. The Plan denied your request. The Plan says the records do not support the codes billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 71045 is not supported in the medical record. Specifically, there is no evidence that a chest x-ray was performed. Fluoroscopy is not a chest x-ray. Stand-alone fluoroscopy should be billed with a fluoroscopy code. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 19, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the services are not considered urgent/emergent in nature. Services rendered by non-participating 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 July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forneedle electromyography services (CPT 95874) provided to the enrollee on July 8, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCurrent Procedural Terminology (CPT) code 95874 remains not supported.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 95874 is "Needle electromyography for guidance in conjunction with chemo denervation (List separately in addition to code for primary procedure)."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the documentation does not support that needle electromyography was used for guidance in conjunction with chemo denervation.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forneedle electromyography services (CPT 95874) provided to the enrollee on July 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional LogistiCare mileage.You asked the Plan to pre-approve additional LogistiCare mileage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you are asking for a total of 53 miles per one-way trip to your destination. The Plan says your contract clearly states you are only covered for up to 50 miles per one-way trip.Medicare does not cover transport 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. The Plan covers a maximum of 36 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are asking for a total of 53 miles per one-way trip to your destination. Your contract clearly states you are only covered for up to 50 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approveadditional LogistiCare mileage.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram rendered to you on May 22, 2019.You asked the Plan to waive the copayment forthese services. You say that there is no copayment for a screening mammogram.The Plandenied 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 $25 copayment for x-ray services. Review of the file shows that you received a diagnostic mammogram on May 22, 2019. You have been asked to pay a $25 copayment for these services. These services fall within the x-ray services 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 forthe mammogram rendered to you on May 22, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on January 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network radiology services. You say that the services in dispute were medically reasonable and necessary.The Plan denied your request. The Plan says there is no valid referral for this 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 payfor these items/services.Therefore, we decided that the Plan does not have to pay forradiology services provided on January 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care on August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for nursing facility care. You say that our provider cannot deny any medical services that were essential for patient health treatment.The Plan denied your request. The Plan says the primary care physician did not refer the member. The Plan says that the referring facility is also out-of-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 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 fornursing facility care on August 26, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve PET scan. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this PET scan is correct, because the documentation does not support medical necessity for this test.
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 PET scan. Our reviewer says that you do not meet the Medicare criteria for the requested PET scan. Our physician reviewer found malignancy is not strongly suspected given the negative non-contract Computed Tomography (CT) test. If clinically indicated a biopsy could be done, but your condition does not necessitate this PET scan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Positron Emission Tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shingles vaccine received on October 11, 2019.You asked the Plan to pay forthe shingles vaccine. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine received on October 11, 2019.