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

We decided that the Plan does not have to pre-approve the total knee replacement services to be provided by
out of network (OON) orthopedic provider.
You asked the Plan to pre-approve the OON orthopedics consultation. You say that you have had bad
experiences with the network doctor and the hospital he uses. You feel that you would get the best care with the
requested OON provider. The Plan denied your request. The Plan says you were informed that the network
office has other surgeons able to provide this care and that they are able to treat you at a different hospital if
you wish. As such, there is no need for OON referral at this time.
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 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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the total knee replacement services to be provided by out of network (OON) orthopedic provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs continued ventilator weaning, aggressive pulmonary hygiene, rehab therapy, and daily physician visits.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including tracheostomy care and CPAP management, surveillance laboratory studies, hemodialysis, tube feedings,and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care.There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imbruvica 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 self-administered drugs are not covered.
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 Imbruvica for the enrollee..
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rinvoq
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 self-administered drugs are not covered.
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-approve Rinvoq
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0483), blood oxygen level measurement (94760), and the breathing capacity test (94010) provided by the out of network provider on August 19, 2019.
You asked the Plan to pay for these services. You say that the services provided to the enrollee were clinically appropriate and medically necessary. The Plan denied your request. The Plan says the services provided were not considered urgent or emergent in nature. The services were provided by an out of network provider at an out of network facility, without prior authorization as required under the Plan benefits.
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 provider and the facility in this case are not network providers 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 drug testing (G0483), blood oxygen level measurement (94760), and the breathing capacity test (94010) provided by the out of network providers on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a meningococcal conjugate vaccine (90734) provided on September 17, 2019.
You asked the Plan to pay for a meningococcal conjugate vaccine. You say that your doctor told you these vaccine was necessary. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a meningococcal conjugate vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a meningococcal conjugate vaccine. Therefore, we decided that the Plan does not have to pay for a meningococcal conjugate vaccine (90734) provided on September 17, 2019.
Benefits for a meningococcal conjugate vaccine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller
harness (E2313) and electronic connector 2 power options (E2311).
You asked the Plan to pre-approve the upgraded electronics. You say that the upgraded electronics are not
medically necessary. The Plan denied your request. The Plan says the upgraded electronics 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 the upgraded electronics. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no indication these devices are critical to the overall functioning of the power
mobility device and/or will allow for significant enhanced mobility related activities of daily living
performance and/or mobility. These are convenience items and not 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 the upgraded electronics have not been met. Therefore, we decided that the Plan
does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) and
electronic connector 2 power options (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar injections for enrollee.You asked the Plan to pre-approve the requested injections. You say that the enrollee was told he is allowed to repeat his radio frequency every six months.The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. only two neurotomy treatments are covered in a year.The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy is only covered under certain medical indications. 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 requested injections. Our physician reviewer found that the enrollee has ongoing low back pain with minimal radiation to his legs. He is taking both Tramadol and oxycodone for pain. He had RFA of the Right L2, L3, L4 and L5 Medial branches on May 29, 2019, and then Left L2, L3, L4, L5 RFA on June 12, 2019. He achieved significant pain relief for 9 months,but the pain has returned. The criteria cover no more than 2 RFA sessions in a rolling 12-monthperiod. Because the enrollee received4 levels in 2 separate sessions, the request for repeat injections represents over-utilization within the 12-monthperiod. Therefore, the request is deemed not medically reasonable or 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 the requested injections have not been met.Therefore, we decided that the Plan does not have to pre-approve lumbar injections for enrollee
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 won't get the same care at a skilled nursing facility. 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 records show that you were admitted to the hospital on January 27, 2020 after a stroke with right sided weakness. You underwent surgery on February 3, 2020. The note dated February 5, 2020 states you need minimal assistance with bed mobility and sitting up. You are able to walk 20 feet using a rolling walker. You have no complex, medical, or nursing issues that require the intensity of services provided at an IRF. You do not require 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Computed Tomography (CT) scan of the
head (70450) provided May 18, 2019.
You asked the Plan to waive the coinsurance for the CT scan. You say that the full amount of the service
should be reimbursed. The Plan denied your request. The Plan says the correct cost sharing has been applied.
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 the plan will reimburse
up to 50% of the allowable amount for covered Advanced Imaging Services.
You have been asked to pay a 50% coinsurance for the CT scan. The CT scan falls within the Advanced
Imaging 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 coinsurance for a Computed
Tomography (CT) scan of the head (70450) provided May 18, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure nutritional enteral formula (B4152).
You asked the Plan to pre-approve Ensure nutritional enteral formula (B4152). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested nutritional enteral formula (Ensure) is not covered in this case.
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition products administered orally are not covered. We looked at the file and Medicare rules. The file shows the requested Ensure will be administered orally and not through a feeding tube. Based on this information, we decided that Medicare rules for coverage of enteral nutrition have not been met. Therefore, we decided that the Plan does not have to pre-approve Ensure nutritional enteral formula (B4152).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from August 1, 2019 to August 12, 2019.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy 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 physical therapy services provided from August 1, 2019 to August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foran infectious agent detection by nucleic acid using amplified probe technique (87798) provided on August 29, 2019 by out of network provider.You asked the Plan to pay foran infectious agent detection by nucleic acid using amplified probe technique. You say that the AMA has not identified more specific codes for the individual pathogens listed as CPT code 87798. By AMA definition, procedure 87798 each organism is identified on the lab report that is included. These are not duplicate charges.The Plan denied your request. The Plan says non-urgent services were not authorized because the provider is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services which takes precedence over the claim system denial. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medicalnecessity 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 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 foran infectious agent detection by nucleic acid using amplified probe technique (87798) provided on August 29, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar provided on May 21, 2019.
You asked the Plan to pay for the cervical collar (L0180). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no supporting information in the medical report for neck pain.
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. The medical records do not support medical necessity. Based on this information, we decided that Medicare rules for coverage of the cervical collar (L0180) have not been met. Therefore, we decided that the Plan does not have to pay for the cervical collar provided on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided at an urgent care center (S9088) provided on October 4, 2019.
You asked the Plan to pay for the urgent care services. You say that you received services from the out-of-network urgent care because your PCP was not taking patients that day. The Plan denied your request. The Plan says CPT Code S9088 is not a covered benefit under Medicare or your Plan.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9088 is not supported in the record. Specifically, per Medicare, S9088 is not a valid code for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the urgent care services have not been met. Therefore, we decided that the Plan does not have to pay for services provided at an urgent care center (S9088) provided on October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 12, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on April 10, 2019.You asked the Plan to pay forlab tests. You say that an in-network laboratory could not be utilized, and these tests are in fact covered.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support coverage of these tests.The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due. The rules also say that a physician order or clear intent to order specific lab services is required for covered lab services.We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order these specific lab services, and the documentation does not show that these tests were ordered for medically necessary purposes to justify coverage of this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided thatthe Plan does not have to pay forlaboratory testing provided on April 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider 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 available from network providers.
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 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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network provider for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH care is medically necessary and appropriate for the enrollee's continuation of acute services.The Plan denied your request. The Plan says LTACH services are not medically necessary. The plan says that the services that would be provided in the LTACH are being given to the enrollee in the current health care setting.ThePlan 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 fileand 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's ongoing care needs include respiratory care including tracheostomy care with ventilator support and weaning, surveillance laboratory studies, telemetry, tube feedings, intravenous antibiotics, hemodialysis, restraint care and safety monitoring, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital(LTACH) services.