Persius/hicric huggingface dataset:
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 requires continued medical management and needs intensive therapies.The Plan denied your request. The Plan says medical necessity cannot be established for IRF 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 the documentation reveals that this enrollee has uncontrolled atrial fibrillation which would not make her appropriate for transfer to a therapy program. Her acute medical needs are not completely stabilized. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee's functional level is already at 150 feet with assistive device contact guard and min assist to supervision for transfers. She does not require therapy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre 14 Day Sensor and Reader. You asked the Plan to pre-approve a FreeStyle Libre 14 Day Sensor and Reader. 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 the requested items.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Therapeutic CGMs and related supplies are covered by Medicare when all of the coverage criteria above are met. In this case, the file does not show that you have been using a BGM and testing four or more times per day and the file does not show that you are insulin-treated with three or more injections of insulin per day or a Medicare-covered CSII pump. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14 Day Sensor and Reader have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor and Reader.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 9,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. 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 a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were 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 drug testing
services provided to the enrollee on May 9, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthrodesis with instrumentation and allograft for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has progressively worsening and severe back pain radiating into his buttocks and down both legs. Signs/symptoms are reported consistent with severe neurogenic claudication. Functional limitations have been documented in activities of daily living. Current evidence based medical literature would support the surgical request on the basis of persistent pain, signs/symptoms of neurogenic claudication, functional limitations, failed conservative treatment, and severe multifactorial stenosis. There is plausible need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, this request for L2-L5 transforaminal lumbar interbody fusion with instrumentation and allograft, and L2-L5 posterior decompression would be considered the standard of care and is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve arthrodesis with instrumentation and allograft for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services.The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for these services to be ordered via telehealth.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent transportation.You asked the Plan to pre-approve non-emergent transportation. The Plan denied your request. The Plan says that this is not medically necessary. 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 non-emergent transportation when deemed necessary. We looked at your request, the records in the case file, and the rules. The file does not include any medical records to confirm this transport is medically necessary. Based on this information, we decided that the Plan's rules for coverage of non-emergent transportation have not been met.Therefore, we decided that the Plan does not have to pre-approve non-emergent transportation.
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. The Plan denied your request. The Plan says IRF admission 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly max assist for functional transfers and activities of daily living, and a less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit and/or participate in an IRF level of care. 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 assistant surgeon services rendered to the enrollee on October 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider type is not covered.
The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS. We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. 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 for the assistant surgeon services rendered to the enrollee on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 01480) provided to the enrollee on June 7, 2019. You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the billed procedure -CPT 01480 -was denied because it is a column I procedure to the previously paid column II procedure -CPT 99213. Additionally, anesthesia was not needed in this case. 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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found according to guidelines from the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures under most routine circumstances do not require anesthesia care other than local anesthesia. The review has determined that anesthesia services (CPT 01480) provided to the enrollee on June 7, 2019 were not medically necessary and reasonable. 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 not been met.Therefore, we decided that the Plan does not have to pay for anesthesia services (CPT 01480) provided to the enrollee on June 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay for physician services provided to the enrollee from January 22, 2018 to January 23, 2018.You asked the Plan to pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until November 12, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plandoes not haveto pay forphysician services provided to the enrollee from January 22, 2018 to January 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical and thoracic radiofrequency ablation (RFA).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewerfound the enrollee has chronic neck and occipital pain. She had one set of cervical medial branch blocks (MBBs) that recorded as providing incomplete relief. The Medicare rules require two sets of diagnostic MBBs with greater than 80 percent pain relief. The records do not support that the RFA meets the criteria for coverage and is medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvecervical and thoracic radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on November 14, 2018 at the in-network rate.
You asked the Plan to pay for these services. You say that the services should be processed at the in-network rate due to plan directed care. The Plan denied your request. The Plan says the claim was paid correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 40% per day, per provider for out-of-network Medicare-covered lab services.
Review of the file shows that the enrollee received laboratory services from an out-of-network provider on November 14, 2018. The enrollee has been asked to pay 40% per day, per provider for these services. These services fall within the out-of-network Medicare-covered lab 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.
The referring provider and the Plan's provider directory does not show that this provider was an in-network provider, so plan directed care does not apply.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on November 14, 2018 at the in-network rate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99326) provided on April 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe domiciliary or rest home visit. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 fora domiciliary or rest home visit (99326) provided on April 18, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyrdocodone-Acetaminophen for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has chronic lumbar spinal pain.The Plan denied your request. The Plan says that this is not covered because it is taken orally.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-approveHyrdocodone-Acetaminophen for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe 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 waive the copayment for a breast ultrasound provided on October 14, 2019.
You asked the Plan to waive the copayment for a breast ultrasound. You say that you should not owe a copayment for breast cancer screenings. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $100 copayment for diagnostic procedures and tests. You received a breast ultrasound on October 14, 2019. A breast ultrasound is considered diagnostic, not preventative. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a breast ultrasound. A breast ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 for a breast ultrasound provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildup for E. Alfaro.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered. 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.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 pre-approvecore buildup for E. Alfaro.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 4Kscore test provided to the enrollee on September 12, 2019.
You asked the Plan to pre-approve the test. You say that this should be paid for. The Plan denied your request. The Plan says the use of the 4Kscore test algorithm is non-covered, regardless of how the test is being used.
The Plan must follow Medicare rules. Medicare rules say that the 4K score test is not a covered service The available evidence does not currently show the 4K score test to be medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve the 4Kscore test provided to the enrollee on September 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from June 1, 2019 through June 30, 2019 provided by an in-network provider.You asked the Plan to waive the copayment for SNF care. You say that you should not be responsible for the SNF charges due to being under the impression there would be no charge.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from June 1, 2019 through June 30, 2019 provided by an in-network provider. You pay a $0 copay per day for days 1-20 and you are asked to pay a $172 copay per day for days 21-100 for in-network Medicare-covered SNF stays. 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 SNF care from June 1, 2019 through June 30, 2019 provided by an in-network provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for re-evaluation of physical therapy and electrical stimulation providedon October 14, 2019.You asked the Plan to pay for the re-evaluation of physical therapy and electrical stimulation. 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 thatthe 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 providerwith 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 for re-evaluation of physical therapy and electrical stimulation provided on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete blood count rendered on October 11, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 85025 is not supported.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 for the complete blood count rendered on October 11, 2019.