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

We decided that the Plan does not have to pre-approve a CardioMEMS HF System.You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested CardioMEMS HF System is medically necessary.The Plan denied your request. The Plan says the requested CardioMEMS HF System is 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 a CardioMEMS HF System. Our reviewer says that the requested CardioMEMS HF System is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, obesity, chronic kidney disease and NYSHA Class III congestive heart failure with preserved ejection fraction requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or 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 a CardioMEMS HF System have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF System
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs intensive rehab to regain strength.The Plan denied your request. The Plan says the criteria for IRF care 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 the enrollee was admitted with dehydration and hyponatremia and has spent the last month in a nursing facility. The complexity of the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT or OT but the patient 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by requested provider.You asked the Plan to pre-approve the physician's services. You say that you have been to this physician and you like him. You say this physician specializes in the neck area where all of your problems are and he knows about the medical problems with your neck and spine. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by requested provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0140) provided December 20, 2018.
You asked the Plan to pay for the dental services. You say that please reconsider the denial of the claim as you are in-network. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network dental provider.
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. The health plan contract says The plan does not cover dental procedures received from an out of network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0140) provided December 20, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (urothelial) gene expression profile testing (CxBladder test) provided on September 24, 2019.You asked the Plan to pay for CxBladder test. You say that this testing was medically necessary.The Plan denied your request. The Plan says the denial of payment for this test is correct, because this test was not medically necessary and was not covered by Medicare on this date of service.The Plan must follow Medicare rules. Medicare rules say that CxBladder testing with procedure code 0012M was not covered by Medicare for date of service September 24, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder test have not been met.Therefore, we decided that the Plan does not have to pay for oncology (urothelial) gene expression profile testing (CxBladder test) provided on September 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine and administration provided on November 16, 2019.
You asked the Plan to pay for these services. You say that you were told this was covered with no cost. The Plan denied your request. The Plan says that this vaccine is covered under Part D. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the vaccine and administration provided on November 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 5, 2019.You asked the Plan to waive the copayment for the ambulance ride. You say that you should not be charged an additional ambulance copayment for the hospital transfer. 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 costsharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment per date of service regardless of the number trips for in-network ground emergency ambulance. The enrollee has been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sit-to-stand frame/table system and accessories.
You asked the Plan to pre-approve a sit-to-stand frame/table system (E0637) and accessories. You say that the enrollee needs a sit-to-stand frame/table system to achieve standing. The Plan denied your request. The Plan says a sit-to-stand frame/table system is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is noncovered. Therefore, we decided that the Plan does not have to pre-approve a sit-to-stand frame/table system and accessories.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that the enrollee tried and failed Monovisc but did well with Synvisc-One. The Plan denied your request. The Plan says the denial of authorization for Synvisc-One is correct, because the Plan requires a trial of Orthovisc before it will approve Synvisc-One.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Synvisc-One. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Orthovisc. The documentation does not support that Orthovisc would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Synvisc-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 22, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab tests billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cardiac Positron Emission Tomography (PET) scan (78492).You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says rules for coverage were not 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 pre-approve the PET scan. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the patient has some coronary risk but no documented symptoms concerning for ischemia, no documented cardiac physical exam abnormalities and no documented ischemic electrocardiographic abnormalities. In this circumstance the records do not support the medical necessity for cardiac PET scanning.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 not been met.Therefore, we decided that the Plan does not have to pre-approve a Cardiac Positron Emission Tomography (PET) scan (78492).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 24 routine transportation trips.
You asked the Plan to pre-approve these additional trips. You say that you need these trips in order to see your doctors and get routine lab testing. The Plan denied your request. The Plan says the record shows that you have 12 one-way trips remaining after the 12 you have used. No trips beyond this limit can be approved.
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 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you will have exhausted the Plan maximum benefit for coverage of routine transportation when you use your 24th trip. Therefore, we decided that the Plan does not have to pre-approve an additional 24 routine transportation trips.
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 the enrollee's level of function would benefit from an intensive rehab program.The Plan denied your request. The Plan says criteria for this level of care have not been 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 the enrollee was admitted to the hospital after a fall. She had no acute findings on CT scan. The complexity of the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the acute inpatient rehabilitation facility care admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility admission.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 that the member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Speech therapy is indicated for treating impairments of dysphagia, cognition, and communication. However, the enrollee is ambulating greater than household distances and is performing essential activities of daily living with minimal assistance and does not require an intensive rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact the member's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at a skilled nursing facility level.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found in the case of this enrollee, complicated urinary tract infection (UTI) and sepsis warranted IV antibiotics, stenting, wound care, and monitoring in an acute care facility, which was appropriate. The most current notes describe significant improvement to the extent that it is unlikely more than 25 days of acute care services would be needed. Based on the clinical progression, soon transfer to a lower level of care may be appropriate for receiving the required services. The services proposed at the LTACH are already being received and covered and will soon be available at a lower level of care. Therefore, this request for LTACH services will be considered not 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a consultation to be provided by "the doctor". You asked the Plan to pre-approve thephysician's services for a consultation. You say that you have not found improvement from other doctors and a friend recommended this physician and you believe it would be beneficial to have a consultation. The Plan denied your request. The Plan says you must use in-network providers to receive coverage for your medical care.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.We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvephysician's services for a consultation to be provided by "the doctor".
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 8, 2019.
You asked the Plan to pay for the psychotherapy 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 psychotherapy services provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on June 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and physician services. You say that you would like to have this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider 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 for an office visit and physician services provided on June 20, 2019 by an out of network (OON) provider.