Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up visit provided on July 10, 2019 by an out of
network provider.
You asked the Plan to pay for a follow-up visit. You say that this situation put them at a disadvantage of not
being able to get pre-authorization. The Plan denied your request. The Plan says no pre-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 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 a follow-up visit provided on July 10, 2019 by an out
of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for custodial care.You asked the Plan to pre-approve inpatient admission for custodial care. The Plan denied your request. The Plan says custodial care is not covered.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Custodial care is not covered by Medicare or your plan. This means inpatient admission for custodial care is also not covered. Based on this information, we decided that Medicare rules for coverage of inpatient admission for custodial care have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient admission for custodial care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar laminectomy 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 the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee had previous fusion
surgery in 2018 with question of failure of L4-5 fusion with screw loosening. There is no official radiology
report describing failure of fusion or screw loosening. The documentation does not support that the requested
lumbar laminectomy is reasonable and 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-approve lumbar laminectomy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of use of the oxygen concentrator.
You asked the Plan to pre-approve continuation of use of the oxygen concentrator. You say that the enrollee needs to continue using the oxygen concentrator. The Plan denied your request. The Plan says the clinical information provided does not support medical necessity.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. We looked at the file, and Medicare rules. The record shows the enrollee's room air saturation is at 98% at rest. Based on this information, we decided that Medicare rules for coverage of continuation of use of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of use of the oxygen concentrator.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee has a history of gastric bypass which contraindicates oral medication, and her risk for hypocalcemia contraindicates Reclast. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Zoledronic Acid before it will approve Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Zoledronic Acid. The documentation submitted does not support that Zoledronic Acid would likely be less effective and/or likely 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve self-administered Ceftriaxone.
You asked the Plan to pre-approve this drug. You say that this drug is medically necessary. The Plan denied
your request. The Plan says self-administered drugs are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve self-administered
Ceftriaxone.
Benefits for this request may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for six physical therapy visits (97162, 97110, 97116, 97140, and 97712) provided from May 6, 2019 to May 23, 2019.
You asked the Plan to waive the copayment for six physical therapy visits. You say that the enrollee was told that there would be no copayment for these services. The Plan denied your request. The Plan says these services processed 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 a $40 copayment for each Medicare-covered physical therapy, occupational therapy, and speech-language therapy visit. The enrollee has been asked to pay a $240 copayment for six physical therapy visits (6 visits x $40 = $240). 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 six physical therapy visits (97162, 97110, 97116, 97140, and 97712) provided from May 6, 2019 to May 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need the services to be approved. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital on January 29, 2020 with peripheral vascular disease and had a resulting surgical procedure. You have significant mobility limitations and need maximum assistance with basic transfers and activities of daily living. The records do not show that you have complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy, but it is not clear that you would be able to fully benefit from and participate in an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) and test (80305) provided on January 8, 2019.
You asked the Plan to pay for the office visit and test. You say that it is too late for the provider to bill the primary insurance so it is now the Plan's responsibility to pay the claim. The Plan denied your request. The Plan says this claim must be submitted to your primary insurance.
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 bill directly 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 has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the office visit and test until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit (99203) and test (80305) provided on January 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and CT scan of the pelvis for the enrollee.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has monoclonal gammopathy of unknown significance. The submitted records contain no evidence to support the use of CT scanning at this time. The requested CT scans of the chest and abdomen/pelvis are not reasonable or medically 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and CT scan of the pelvis for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged psychotherapy services rendered to the enrollee on May 1, 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 99354 is 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 99354 is prolonged outpatient service requiring direct
patient contact - first hour.
We find that CPT code 99354 is not supported in the medical record. Specifically, there is no documentation of
the total duration of time spent with the enrollee. 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
prolonged psychotherapy services rendered to the enrollee on May 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the therapy services received from June 21, 2019 to July 23, 2019.
You asked the Plan to waive the copayments for the therapy services. You say that the enrollee had met their annual maximum out of pocket for these services. The Plan denied your request. The Plan says the claims were processed correctly per the enrollee's plan 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services. Review of the file shows that as of after the June 21, 2019 date of service, the enrollee had an out-of-pocket amount of $3,716.42. Therefore, the enrollee had a remaining amount of $783.58 to pay before the out-of-pocket maximum had been met.
The enrollee has been asked to pay a $40 copayment for the therapy services. the therapy services fall within the outpatient rehabilitation 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 copayments for the therapy services received from June 21, 2019 to July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 29, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area 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 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 laboratory services. 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 laboratory services provided on August 29, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU) treatment of the prostate.
You asked the Plan to pre-approve the HIFU treatment. You say that this treatment is shown to be safe and effective compared to other therapies and should be covered. The Plan denied your request. The Plan says that this is an experimental procedure at this time.
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 the HIFU treatment. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with stage T1c Gleason's grade 3+4 adenocarcinoma of the prostate. Pre-biopsy PSA was 3.12 ng/mL. High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. HIFU was FDA approved for prostate gland ablation October 9, 2015. Numerous clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, incontinence, and bowel injury. 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 HIFU treatment have been met. Therefore, we decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU) treatment of the prostate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 4, 2019 and June 18, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral for this service
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 physician's services provided on June 4, 2019 and June 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on September 5, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria for the orthoses were not 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 pay for the knee orthosis (L1851) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960). Our physician reviewer found the enrollee's chief complaints were chronic pain in the Knee Left, Knee Right, and Shoulder Left, documented in 2 separate notes. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 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 knee orthosis (L1851) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered to you on October 4, 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 Medicare does not cover routine vision services and
eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the eye refraction rendered to you on October 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan 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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage IIIB vulvular cancer and has had three prior PET scans post-treatment and a computed tomography (CT) scan on January 24, 2020 that showed no evidence of disease. A surveillance PET scan is not considered the standard of care and is not reasonable or 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-approve a positron emission tomography (PET) scan for the enrollee.