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

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network specialist for the enrollee.You asked the Planto pre-approvethe referral. You say that thisis medically necessary.The Plandenied your request. The Plansaysthere is no gap issue, and there are network providers 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network specialist for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy services provided , through December 3, 2020.You asked the Plan to pay forthe psychotherapy services. The Plan denied your request. The Plan says there were available par providers who could work with this member.The Plan must follow Medicare rules. Medicare rules say that a Masters of Social Work is not eligible to participate in the Medicare program.We looked at the file and Medicare rules. The provider at issuein this caseis aMasters of Social Work.Medicare says that aMasters of Social Workis not eligible to participate in the Medicare programTherefore, we decided that the Plan does not have to pay forpsychotherapy services provided by
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you are a fall risk and diagnosed with diabetes. You state that it is hard for you to take care of yourself and avoid falling and severe injury.The Plan denied your request. The Plan says the stay is not medically necessary.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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for rib fractures after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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-approveacute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding scooter (E1399).

You asked the Plan to pre-approve a folding scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says DME is only approved for use in the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a folding scooter (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe interrogation device evaluations (G2066, 93298) provided  by an out of network (OON) provider.You asked the Plan to pay forinterrogation device evaluations. You say that to your understanding the patient was supposed to transition to an in-network provider after three treatments. The patient did not transfer. You are requesting reconsideration for the claims to be paid.The Plan denied your request. The Plan says the services were rendered out of area and no evidence was provided that the services were urgent or emergent.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 theitem/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 interrogation device evaluations (G2066, 93298) provided  by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you cannot go home and need intensive therapy.The Plan denied your request. The Plan says the stay is not medically necessary.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 requestto 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. You were admitted for weakness and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documentedneed for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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-approveacute IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0676) provided .You asked the Plan to pay fora pneumatic compression device. You say that the item was medically necessary for the enrollee's condition.The Plan denied your request. The Plan says this is not a covered service.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0676) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99214) provided by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say thatyou do not want to change your primary care provider.The Plan denied your request. The Plan says criteria for OON coverage for the service were not met.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 office visit (99214) provided  by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay forperiodontal maintenance services (D4910) received.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe benefit 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. The Plan covers periodontics once every six months.A review of the file shows that periodontics were received less than six months before the date of service at issue in this case, . Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forperiodontal maintenance services (D4910) received
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forlaboratory services received .You asked the Plan to pay forthe services. You say that this is medically necessary.The Plan denied your request. The Plan says that genetic cancer susceptibility panel testing using next generation sequencing is considered investigational.The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee meets the criteria for this request. She has metastatic adenocarcinoma and there is no documentation indicating that she has  been previously tested using the same NGS test for the same primary diagnosis of cancer.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 services have been met.Therefore, we decided that the Plan has to pay forlaboratory services received.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 toopen 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 OneTouch test strips.

You asked the Plan to pre-approve OneTouch test strips. You say that you would benefit from additional glucose testing strips. The Plan denied your request. The Plan says your request for an increased supply of testing strips is not medically necessary or reasonable.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OneTouch test strips have not been met. Specifically, there is no documentation indicating an increased supply of test strips is medically necessary. This means the items cannot be approved. Therefore, we decided that the Plan does not have to pre-approve OneTouch test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortelephone evaluation and management service (CPT code 99441) provided .You asked the Plan to pay forthe service. You say that Teledoc is covered under this plan.The Plan denied your request. The Plan says their records show that you had primary insurance coverage effective .The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the billdirectly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan states in order to process your claim, the Plan would need a copy of your primary insurance explanation of benefits for this date of service.As the secondary insurer, the Plan cannot be held responsible for the service until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay fortelephone evaluation and management service (CPT code 99441) provided
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecombination chemotherapy Tecentriq, carboplatin.You asked the Plan to pre-approvecombination chemotherapy Tecentriq, carboplatin. You say that the requested combination chemotherapy Tecentriq, carboplatin is medically necessary.The Plan denied your request. The Plan says the requested combination chemotherapy Tecentriq, carboplatin is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 combination chemotherapy Tecentriq, carboplatin. Our reviewer says that the requested combination chemotherapy Tecentriq, carboplatin is not medically necessary. Our physician reviewer found the enrollee is diagnosed with malignant neoplasm of lower lobe, left bronchus or lung.  First-line treatment (in combination with paclitaxel [protein bound] and carboplatin) of metastatic NSCLC in adults with no EGFR or ALK genomic tumor aberrations is not FDA approved for the enrollee's diagnosis. The enrollee is EGFR negative (VUS considered negative) but no results for ALK provided.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of combination chemotherapy Tecentriq, carboplatin have not been met.Therefore, we decided that the Plan does not have to pre-approvecombination chemotherapy Tecentriq, carboplatin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided .You asked the Plan to pay forthe lumbar-sacral orthosis. You say that this item was medically necessary for the enrollee's condition.The Plan denied your request. The Plan says there is no evidence the prescribing physician ever saw member.The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is covered when criteria is met as listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).You asked the Plan to pre-approvea CGM. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet Medicare criteria for a CGM.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabeteswho 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 use insulin with at least three daily injections and does not 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 a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (D0160, D1999) received.You asked the Planto pay forthe services. You say that you have pain in your teeth.The Plandenied your request. The Plansaysthere is no supplemental benefit to cover this service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plandoes not haveto pay fordental services (D0160, D1999) received .
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not beenmet.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe Esophagogastroduodenoscopy (EGD) services provided.You asked the Plan to waive the copayment forthe EGD. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an EGD in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Outpatient hospital services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an EGD in an outpatient hospital setting  You have been asked to pay a $250 copayment for the EGD. The EGD falls within the Outpatient hospital 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 Esophagogastroduodenoscopy (EGD) services provided2020