Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 receiver and supplies.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of diabetes.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not use insulin three or more times per day to treat her high blood sugar and do not test blood sugar four or more times per day. You have not been using insulin multiple times (3 or more) a day. Your treatment does not require frequent adjustment on the basis of testing results. 

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 pre-approve a Freestyle Libre 2 receiver and supplies.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ConfirmMDx testing (81551) provided on July 15, 2020.

You asked the Plan to pay for the ConfirmMDx. You say that you would like reconsideration as this testing is used to guide urology decisions on repeat biopsy for patients with a previous negative prostate biopsy but considered high risk for prostate cancer. The Plan denied your request. The Plan says that molecular genetic screening testing is not a Medicare benefit for the diagnoses aslisted on the claim.

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 follows these rules. 

The ConfirmMDx testing was ordered by a contract provider. The file does not show that the plan provided notice that the ConfirmMDx would not be covered. Under Medicare rules, this means the ConfirmMDx is considered approved by the plan. Additionally, this testing is directly related to the member's condition and is not a screening test. Therefore, we decided that the Plan has to pay for the ConfirmMDx testing (81551) provided on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CancerNext - Expanded genetic testing panel.

You asked the Plan to pre-approve the panel. You say that testing every five years is suggested due to increased testing capabilities. The Plan denied your request. The Plan says Medicare does not endorse repeat genetic panels testing in general.

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 panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a personal history of colon care diagnosed seventeen years ago. You underwent genetic testing six years ago. There is no evidence that you are currently undergoing evaluation for signs or symptoms thought to be cancer. There is no evidence that you need genetic testing to either diagnose a cancer or help determine the best treatment for an already diagnosed cancer. As such, the requested genetic testing is not shown to be medically necessary or 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve the CancerNext - Expanded genetic testing panel.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for patients with stable coronary artery disease.

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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found you are already being managed for risk factor modification for your higher cardiovascular risk with statin therapy and your LDL is at goal for a patient with diabetes. You are being managed for hypertension as well and a prior recent evaluation, including a nuclear stress test, showed no evidence of ischemia. Coronary calcium scoring would be indicated for further risk stratification in a patient who is at intermediate risk for CVD to determine the need for cholesterol lowering therapy and other aggressive risk factor modifications. You have known diabetes and are at high 10 year risk for CVD and are being aggressively treated to modify your risk factors per AHA/ACC guidelines including with high dose statin therapy. Coronary calcium scanning will not change this guideline directed medical therapy and is not indicated to further guide your management. It is not medically necessary or indicated based on published guidelines in this clinical situation. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the heart.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on October 13, 2020.

You asked the Plan to waive the copayment for lab work. You say that you were never notified that you would have to pay for lab work. The Plan denied your request. The Plan says the correct copayment 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 you must pay a $10 copayment for outpatient diagnostic tests/in-network/labs. 

You have been asked to pay a $10 copayment for lab work. The correct copayment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/in-network/labs 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 lab work provided by a participating provider on October 13, 2020
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 12, 2020, to July 13, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says that the enrollee did not need full inpatient level of services.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 12, 2020, to July 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health visits provided from March 1, 2020, to March 15, 2020.

You asked the Plan to reimburse you for the home health visits. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to reimburse you for the home health visits provided from March 1, 2020, to March 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 5, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided by on April 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe cardiology services to be provided by an out of network (OON) provider in Arizona.You asked the Planto pre-approvethe OON cardiology services. You say that you chose this Plan as you were able to obtain coverage in Arizona. However, you do not currently feel safe to go to listed facilities due to COVID. You have seen the OON cardiologist in the past and wish to see him for your care.The Plandenied your request. The Plansaysyour coverage is limited to plan designated providers within the Arizona travel area.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 could 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 Plandoes not haveto pre-approvethe cardiology services to be provided by an out of network (OON) provider in Arizona.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 10, 2020.

You asked the Plan to pay for the laboratory 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 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 November 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for behavioral health treatment services for the enrollee.

You asked the Plan to pre-approve the referral. You say that now is not the time to begin anew with a clinician that you do not know or trust. The Plan denied your request. The Plan says the service requested is to be rendered by a provider who is not under contract with the health plan.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 referral. Our reviewer says that the requested continuation of care is not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, this enrollee does not require treatment by an out-of-network provider as the medical plan is able to provide a psychotherapist for the treatment of this enrollee's condition. The enrollee's condition is not considered urgent/emergent condition. Utilization of an network providers assures a credentialed and clinically maintained individual assured by the medical provider to a certain standard 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 the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for behavioral health treatment services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on September 9, 2020.

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 there was no claim for the ordering physician.

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 requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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 insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. 

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 a knee orthosis (L1833) provided to the enrollee on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2020.

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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial finger prosthesis (L7499).

You asked the Plan to pre-approve this item. You say that this item is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not payable as it has been coded incorrectly.

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 this item. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that a partial finger passive silicone prosthesis with three fingers is not medically necessary as the request appears to exceed the patient's medical need and the documentation from the treating medical practitioner does not reveal why a standard partial hand with fingers prosthesis does not meet the patient's medical need. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial finger prosthesis (L7499).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan Hycela treatments for the enrollee.

You asked the Plan to pre-approve Rituxan Hycela treatments. You say that this drug is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Rituxan Hycela treatments. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found at issue is coverage for continued use of Rituxan Hycela (Rituximab/Hyaluronidase Huan, Recombinant. The enrollee is an 81-year-old man with a diagnosis of Small cell B-cell lymphoma, and intra-abdominal lymph nodes. The enrollee was treated for follicular lymphoma in 2017 with 3 cycles of Treanda Rituxan. The enrollee was later retreated and completed 8 weeks of Rituxan in July 2019. Repeat imaging demonstrated increased size of lymph nodes, and a course of 12 cycles of Rituxan Hycela and Revlimid was completed. A CT scan on February 9, 2021 demonstrated interval enlargement of previously identified lymph node within the chest, abdomen and upper pelvis, consistent with disease progression. The provider notes that the increase in retroperitoneal lymphadenopathy is slight, and that enrollee is relatively asymptomatic. The documentation supports that the requested drug is safe and is expected to be effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan Hycela treatments have been met. Therefore, we decided that the Plan has to pre-approve Rituxan Hycela treatments for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic nuclear medicine provided by a participating provider on October 6, 2020.

You asked the Plan to waive the copayment for diagnostic nuclear medicine. You say that you do not believe you should have this copayment. The Plan denied your request. The Plan says the correct copayment 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 you must pay a $195 copayment for outpatient diagnostic tests/nuclear medicine radiological services. 

You have been asked to pay a $195 copayment for diagnostic nuclear medicine. The correct copayment has been applied to the services that were provided. Diagnostic nuclear medicine falls within the outpatient diagnostic tests/nuclear medicine radiological 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 copayment for diagnostic nuclear medicine provided by a participating provider on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on September 19, 2020.

You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with this copayment. You say that you do not think you should have to pay for this. The Plan denied your request. The Plan says the correct copayment 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 you must pay a $25 copayment for outpatient diagnostic tests/x-rays. 

You have been asked to pay a $25 copayment for an x-ray. The correct copayment has been applied to the x-ray that was provided. An x-ray falls within the outpatient diagnostic tests/x-rays 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 x-ray provided by a participating provider on September 19, 2020.