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

We decided that the Plan does not have to pre-approve multi-level lumbar fusion for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is 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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show spinal instability, fracture, or tumor. The criteria for fusion havenot been met.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve multi-level lumbar fusion for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plansays based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the transthoracic echocardiography provided on September 20, 2019.
You asked the Plan to waive the coinsurance for the transthoracic echocardiography. You say that you did not know you would be billed for the services. You say that you cannot pay the bill. The Plan denied your request. The Plan says the coinsurance applied 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered non-radiological diagnostic services from an in-network provider. You have been asked to pay $162.03, which is 20% of the allowed amount for the transthoracic echocardiography. The allowed amount is $850.67 ($850.67 x 20% = $162.03). The transthoracic echocardiography 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 coinsurance for the transthoracic echocardiography provided on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the referring physician is in-network with the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 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 the medical services provided on July 16, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan hasto pre-approvetransthoracic echocardiography with image documentation for the enrollee.You asked the Planto pre-approve the services. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is insufficientclinical information to approve the requested study.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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has complex cardiopulmonary disease and a decrease in LV function noted on his echo 6 months ago. He also was noted to have at least moderately severe aortic stenosis at that time. He is being treated with guideline directed medical therapy. Although there is no recent office visit note, it has been 6 months since his prior echocardiogram which was also obtained in the setting of a pneumonia. In addition to reassessing his LV function now in a more stable clinical situation on a good medical regimen, a repeat assessment of his aortic stenosis is also reasonable as calcific aortic stenosis in the elderly can increase in severity quite rapidly and AVR or TAVR would be considered for treatment if the aortic stenosis was now severe. This isespecially true given the decrease in LV function which was noted on the August 2019 echo. Based on these clinical findings six months ago, reassessment of the severity of the aortic stenosis and the depressed LV function by echocardiography is medically necessary and appropriate at this point in this enrollee's 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 services have been met.Therefore, we decided that the Planhas to pre-approvetransthoracic echocardiography with image documentation for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProlia/Denosumab injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of medical necessity.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee is post-menopausal and has seropositive rheumatoid arthritis. A dexa bone scan reported 1/13/20 notes the enrollee has osteopenia. Approved compendia support the use of Denosumab for the diagnosis of osteoporosis. Without the support of documentaiton, medical necessity cannot be determined.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProlia/Denosumab injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab tests. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there is no network deficiency for these services and alternate network providers were found.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 whocan 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 forgenetic testing provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran epidural injection provided on November 8, 2019.You asked the Plan to waive the copayment foran epidural injection. You say that you were not informed that you would owe such a high copayment.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 thePlan clearly says that you must pay a $600 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $600 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 foran epidural injection provided on November 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis and digital scan.You asked the Plan to pre-approve custom breast prosthesis (L8035) and digital scan (L8039). You say that scans are for proper contour of the custom prosthesis.The Plan denied your request. The Plan says Medicare guidelines state a custom breast prosthesis is not reasonable and necessary therefore the imaging is also not covered.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of custom breast prosthesis (L8035)and digital scan (L8039) have not been met.Therefore, we decided that the Plan does not have to pre-approve a custom breast prosthesis and digital scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet injections.You asked the Plan to pre-approve diagnostic facet injections. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that facet injections are covered when the above criteria are met.We askedour 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 diagnostic facet injections. Our reviewer says that the requested diagnostic facet injections are not medically reasonable and necessary. Our physician reviewer found that there is no need to repeat the diagnostic work-up of facet joint pain if the enrollee has previously had 90% pain relief for 6 months from prior RFA. The request to repeat the MBBs is not 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 diagnostic facet injections have not been met.Therefore, we decided that the Plan does not have to pre-approvediagnostic facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).You asked the Plan to pre-approve the hospital bed. You say that  The Plan denied your request. The Plan says Medicare coverage guidelines have not been met.We looked at the file and Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed, or requires attachments which can only be attached to a hospital bed, and requires frequent changes in body position and/or has an immediate need for a change in body position. In this instance, the records do not show that you have a condition that requires positioning of the body in ways not feasible with an ordinary bed, or that you require frequent changes in position without tolerance for delay. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for transforaminalplacement surgery provided on March 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the member's primary care provider did not refer for services. 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 transforaminal placement surgery provided on March 29, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a septoplasty procedure.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 thecase 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 submitted records showthat you have a deviated nasal septum, nasal obstruction, and snoring. You have no improved with medical management. The structure of her nose and nasal passages are causing her to have the symptoms of obstruction and snoring. Therefore, a septoplasty is considered the standard of care for your condition. The procedure 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 been met.Therefore, we decided that the Plan has to pre-approvea septoplasty procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMSdevice (33289 and C2624).You asked the Plan to pre-approve the CardioMEMSdevice. You say that the member urgently needs this device and procedure due to worsening heart failure. The Plan denied your request. The Plan says The member's currentfacility is not enrolled in the study and thus neither the member's plan nor Medicare can make payment for the requested CardioMEMS.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 CardioMEMSdevice. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure.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 CardioMEMSdevice have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMSdevice (33289 and C2624).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the pathology services provided on September 9, 2019 to September 25, 2019.You asked the Plan to waive the copayments forthe pathology services. You say that if your case was handled correctly, it would have saved you many tests. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment for in-network Medicare-covered lab services. You have been asked to pay a $10 copayment for the pathology services on each date of service. The pathology service 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 copayments forthe pathology services provided on September 9, 2019 to September 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided by the Hospital on May 8, 2019.You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree with the charges.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 each outpatient hospital visit. You received an EGD provided in an outpatient hospital facility on May 8, 2019. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an outpatient hospital facility visit provided by the Hospital on May 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), second stage implant surgeries (D6011 x2), endosteal implants (D6010 x2), and bone graft at time of implant placement (D6104).You asked the Plan to pre-approvethe guided tissue regeneration, second stage implant surgeries, endosteal implants, and bone graft at time of implant placement. You say that this dental surgery and care is needed because it is due to a medical condition that was brought on by extreme chemotherapy, radiation, and stem cell transplant.The Plan denied your request. The Plan says these services are not medical in nature and are not covered benefitsunder your plan.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 contract clearly states that implant related services are excluded from coverage.Therefore, we decided that the Plan does not have to pre-approvea guided tissue regeneration (D4266), second stage implant surgeries (D6011 x2), endosteal implants (D6010 x2), and bone graft at time of implant placement (D6104).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for DecisionDx-Melanoma gene expression testing provided on March 29, 2019.You asked the Plan to pay forgenetic test. You say that this test is covered by Medicare and was ordered by the enrollee's treating physician.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test was not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not specified whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not show that prior notice was given that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that their decision to deny payment for this test is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay forDecisionDx-Melanoma gene expression testing provided on March 29, 2019