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

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the transport should be covered because the
other half of the transportation services were already paid by the Plan. You asked the Plan to reconsider
providing coverage and issue payment for the transportation services. The Plan denied your request. The Plan
says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 3, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed
incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one
unit of CPT 81479 and the appropriate DEX Z-Code.
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX ZCode.
Based on this information, we decided that Medicare rules for coverage of the testing have not been met.
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 3,
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 based on the documentation provided, this enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Medicare coverage criteria for IRF admission are not met.
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on March 17, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation)
requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative
field.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the psychotherapy services (90832). You say that you would like reconsideration
because your provider rendered medically necessary services in good faith. The Plan denied your request. The
Plan says the utilization of network providers is required when possible and available.
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 14, 2020
by an out of network (OON) provider.
Appeal type: Lab
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 June 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 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 June 18, 2019.
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 need rehabilitation that can monitor your conditions and the medications you are on. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy, but the documentation does not support that your functional status requires an intensive rehabilitation therapy program provided 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (1160F, 3008F) provided on March 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Codes 1160F and 3008F are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (1160F, 3008F) provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve food thickener.
You asked the Plan to pre-approve food thickener. You say that this should be approved because you have a medical condition which requires this. The Plan denied your request. The Plan says this is not a covered benefit under Medicare.
The Plan must follow Medicare rules. Medicare rules say that coverage is allowed for nutritional products when used supplies with a feeding tube. Orally administered nutritional products do not fall into a covered benefit category. Therefore, we decided that the Plan does not have to pre-approve food thickener.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve transfer to Long-Term Acute Care Hospital (LTACH).
You asked the Plan to pre-approve LTACH service. You say that you need a bed due to COVID-19, therefore
the enrollee needs to be transferred to the LTACH. The Plan denied your request. The Plan says that the denial
of authorization for LTACH service is correct.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve LTACH service. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee requires additional acute care services and monitoring. The enrollee does not
appear to be stable for discharge to a lower level of care 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 LTACH service have been met. Therefore, we decided that the Plan has to pre-approve
transfer to Long-Term Acute Care Hospital (LTACH).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT imaging of the abdomen/pelvis and chest.
You asked the Plan to pre-approve the CT imaging. You say that this should be approved as this imaging is necessary for continued treatment of cancer. The Plan denied your request. The Plan says this imaging to check for progression is a part of the clinical trial and cannot be covered by the Plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the CT imaging which is needed to evaluate for progression which is an outcome measure of the clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve CT imaging of the abdomen/pelvis and chest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
January 29, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the 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 $45
copayment per specialist visit. For this date of service, you have been asked to pay the allowed amount of the
claim because this amount is less than the $45 copayment for the specialist office visit.
You have been asked to pay a $41.38 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
you were charged for a follow-up for chest pain and hyperlipidemia.
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 specialist office visit provided on January 29, 2020.
Your complaint about not receiving the electrocardiogram is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 4, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services are not supported.
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 drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that RFA is covered when the above 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 pre-approve the RFA. Our reviewer says that the
requested RFA is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer
found that in order to meet criteria for L4-L5 bilateral facet RFA, dual diagnostic MBBs must be performed.
This has not been done. Further, RFA of the lateral sacral branches is considered experimental/investigational.
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 RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve radiofrequency ablation (RFA).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transportation trip of 120 miles.
You asked the Plan to pre-approve the additional mileage. You say that you have a scheduled procedure and have no way to get to the facility. You feel that the plan should cover the trip regardless of how many miles it is. The Plan denied your request. The Plan says your benefit does not cover trips over 50 miles.
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 routine transportation when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. You are requesting a trip that exceeds 50 miles. There is no provision in the contract which would require the plan to approve more than a 50 mile trip. Therefore, we decided that the Plan does not have to pre-approve a routine transportation trip of 120 miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine ointment.
You asked the Plan to pre-approve the Lidocaine ointment. You say that the enrollee has had good results in
the past with this medication. You say that this drug has helped with the enrollee's post herpetic neuropathy.
You say that, because of the enrollee's age, you do not want to progressed treatment to oral pain medication for
fear of fall risk. You say that the enrollee has not had any relief from topical NSAD use. The Plan denied your
request. The Plan says the drug in dispute is not covered under Part B. The Plan says that the enrollee does not
have Part D coverage through them.
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 Lidocaine ointment.
Benefits for the Lidocaine ointment 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen.
You asked the Plan to pre-approve the abdominal MRI. You say that this is the best imaging to check for this hernia. The Plan denied your request. The Plan says MRI would only be necessary if ultrasound or CT scan were non-diagnostic.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 abdominal MRI. Our reviewer says that the requested imaging is not considered reasonable and necessary. Our physician reviewer found the enrollee is a 78-year-old male with recent findings of bulging in the left groin area with pain concerning for an inguinal hernia. His provider feels that magnetic resonance imaging (MRI) of the abdomen would be best to evaluate this condition. Based on the medical records provided, there is no documentation of a non-diagnostic or equivocal abdominal ultrasound or computed tomography scan. Ultrasound or computed tomography is generally the best initial diagnostic modality for identifying an occult inguinal hernia. MRI would generally be reserved for cases where the ultrasound or computed tomography scan is non-diagnostic. 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 abdominal MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the abdomen.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 23, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves.
You asked the Plan to pre-approve nerve block procedure. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is experimental/investigational.
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 nerve block procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that 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 nerve block procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves.