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

We decided that the Plan does not have to pay foran electrocardiogram (ECG) (93005) provided on August 8, 2019 by an out of network (OON) provider.You asked the Plan to pay foran ECG. You say that you do not agree with the decision and are requesting a reconsideration for the denied service.The Plan denied your request. The Plan says the doctor is a non-network provider who does not work with the member's health plan, and the member self-directed for care. The member's primary care provider did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 theitems/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 foran electrocardiogram (ECG) (93005) provided on August 8, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a liver transplant (47135).You asked the Plan to pre-approvea liver transplant. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that adult liver transplantation when performed on beneficiaries with end-stage liver disease other than hepatitis B or malignancies is 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 liver transplant. Our reviewer says that the service is medically necessary. Our physician reviewer found liver transplantation is the only method of treatment of end stage renal disease that offers the opportunity for recovery. Given your condition and MELD score of19, transplantation is medically necessary. It is argued that you are not eligible for a liver transplant under NCD 260.1 because you have hepatitis B. A perfunctory reading of the NCD indicates that this is incorrect. The proscription on liver transplantation for hepatitis B was in the original NCD noted to be effective in July 1996. The proscription was removed in December 1999 as the second paragraph in the Indications and Limitations of Service clearly reveals.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 liver transplant have been met.Therefore, we decided that the Plan has to pre-approvea liver transplant (47135).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 23, 2019 and September 30, 2019.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the physician does not participate with Medicare and has opted-out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by physician. This provider has opted out of the Medicare program. The file shows that the physician entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the physician services provided on September 23, 2019 and September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 9, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a 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 drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on December 3, 2018.You asked the Planto pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 44025 and 49082 are 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 44025 is colotomy, for exploration, biopsy(s), or foreign body removal. The definition of code 49082 is abdominalparacentesis (diagnostic or therapeutic); without imaging guidance.We find that CPT codes 44025 and 49082 are not supported in the medical record. Specifically, the operative report does not include documentation that a colotomy was performed to supportcode 44025 or documentation of an abdominal paracentesis without imaging guidance to support code 49082. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan doesnot have to pay forthe services rendered to the enrollee on December 3, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Railing Now-Midway 4ft Transitional Handrail purchased on March 21, 2019.You asked the Plan to reimburse you forthe grab bar. You say that because of medical conditions and a recent fall you need grab bars in your bathtub.The Plan denied your request. The Plan says you did not have an in-home safety assessment for the grab bar but we will reimburse you $15.99for the 12 inchMoen grab bar.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, you did not have the required in-home safety assessment first.Therefore, we decided that the Plan does not have to reimburse you forthe Railing Now-Midway 4ft Transitional Handrail purchased on March 21, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLucentis or Eylea intravitreal injections.You asked the Plan to pre-approvethe Lucentis or Eylea injections. You say that you feel that the desired medication should be approved without a trial of the preferred drug.The Plan denied your request. The Plan says step therapy rules require a trial of Avastin for this condition.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-approvethe Lucentis or Eylea injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on step therapy requirements. Our physician reviewer found the enrollee has a diagnosis of Exudative age-related maculardegeneration, bilateral, with active choroidal neovascularization. The medical record notes Lucentis is recommended but the authorization request was made for Eylea. Both require a trial of Avastin prior to use. Bevacizumab (Avastin) has been used for many years as an off-label treatment for neovascular ARMD. Based on clinical trials, this medication has been demonstrated to be effective in the treatment of the enrollee's condition, and has a similar adverse event profile. Therefore, it is unlikely that the required drug, Bevacizumab, would be less effective, and/ or would have adverse effects for the enrollee in this case.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 Lucentis or Eylea injections have not been met.Therefore, we decided that the Plan does not have to pre-approveLucentis or Eylea intravitreal injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 31, 2019.You asked the Plan to pay for the domiciliary or rest home visit.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 service 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 fora domiciliary or rest home visit provided on July 31, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood pressure monitoring provided on September 21, 2019.You asked the Plan to pay for blood pressure monitoring. You say that the Plan should pay this claim.The Plan denied your request. The Plan says ambulatory blood pressure monitoring must be performed for at least 24 hours and services provided during transport are not paid separately.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 A4670is Automatic blood pressure monitor.Blood pressure monitoring is included in the Medicare fee schedule for ambulance services.Therefore, we decided that the Plan does not haveto pay for theblood pressure monitoring provided on September 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay forthe drug testing rendered on July 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is not clear that you can participate in 3 hours of therapies a day.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 physician reviewer found that you were admitted for acute care with advanced Parkinson's disease, and without new identified injury or reversible impairing condition. Your medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. You do not require medical oversight of your condition at an acute hospital level of care.  You require physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. You are limited by the severity of your Parkinson's Disease and comorbid medical conditions. You would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on August 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for pathology services. You say that you do not have any access to patient's demographics prior to date of service nor the patients insurance information.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these 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 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 pathology services provided on August 16, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for enrollee.You asked the Plan to pre-approve IRF care. You say that the enrollee needs consistent care with his daily activities.The Plan denied your request. The Plan says the enrollee is currently not medically stable and needs to remain in the acute care hospital.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 physician reviewer found that the enrollee's current level of function is total assist for feeding, minimal assist for grooming, total assist for toileting, max assist for upper body dressing, total assist for lower boy dressing, max assist for bed mobility, and max assist for toilet transfers. 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 indicates the enrollee had hypernatremia, which was being treated and required continued care in the acute care hospital. A transfer to a rehabilitation program would not be appropriate in the setting of ongoing acute medical issues. The enrollee may benefit and participate in additional physical and occupational therapy, but the enrollee's functional level 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 for enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray (71046) provided on October 8, 2019.You asked the Plan to pay forthe chest x-ray (71046). You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say preprocedural chest X-rays in theabsence of pulmonary or cardiac diseases, chest X-rays in the absence of signs or symptoms, and chest X-rays for minor trauma of the head, lower back or extremities are not the current accepted medical practice. In this case, the CPT Code 71046 is for apreoperative chest x-ray. The Medicare rules list diagnoses which are not supported for medical necessity for preoperative x-rays. The records list a diagnosis code of Z01.818. This is not covered by Medicare. We find that CPT code 71046 is not supported in the record. Specifically, this service is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the chest x-ray (71046) have not been met.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71046) provided on October 8, 2019.
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 August 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 August 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine transportation to see.You asked the Plan to pre-approve routine transportation. You say that the enrollee needs to see this provider.The Plandenied your request. The Plan says the requested trip exceeds the mileage of the transportation benefit.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 trips up to 50 miles. We looked at your request, the records in the case file, and the rules. The trip you are requesting is 77 miles, which exceeds the 50 mile limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveroutine transportation to see.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe refraction services provided October 15, 2019.You asked the Plan to pay forthe refraction services. You say that you are requesting reconsideration of the refraction services.The Plan denied your request. The Plan says refraction services is not a covered benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The Plan contract specifically states thatrefraction services is excluded.We looked at the file and the Plan's rules. refraction services is excluded and is not a covered benefit Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met.Therefore, we decided that the Plan does not have to pay forthe refraction services provided October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora chest x-ray (71046) provided November 7, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that the test was preventative and there should be no copayment.The Plan denied your request. The Plan says you were not eligible for a preventative lung cancer screening. The correct copayment was applied for the x-ray at issue.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 $50 copayment for X-rays. You have been asked to pay a $30.61 copayment for the x-ray. The chest x-ray falls within the X-rays benefit category. The Medicare allowable amount is less than the $50 copayment stipulated in the plan contract. This amount has been charged as the cost-share instead. 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 fora chest x-ray (71046) provided November 7, 2019..
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve osteotomy and bilateral sagittal split osteotomy surgery.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says that it is not a covered benefit unless correction is needed due to a specific medical condition.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that a diagnosis of skeletal deformity characterized by mandibular deficiency and retrogenia was made. This enrolleedoes exhibit a skeletal deformity present congenitally,which is the causative factor of her functional difficulties and pain. The enrolleemeets the criteria for coverage for orthognathic surgery to improve functionthrough correction of her underlying skeletal deformity (mandibular deficiency and retrogenia) due to craniofacial anomaly.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 requested services have been met.Therefore, we decided that the Plan has to pre-approveosteotomy and bilateral sagittal split osteotomy surgery.