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

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring
(CGM) system.
You asked the Plan to pre-approve another CGM. You say that you don't use the Dexcom G5 because the
sensor kept coming off and you couldn't read the numbers. The Plan denied your request. The Plan says your
current CGM, from May 15, 2019, is in working order and meets your needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have the Dexcom G5 CGM. The Dexcom G5 CGM serves the same purpose as the
CGM at issue. The documentation submitted does not show that the Dexcom G5 CGM is irreparably damaged
or that you had a change in medical condition to warrant the CGM at issue. Therefore, we decided that the Plan
does not have to pre-approve a FreeStyle Libre continuous glucose monitoring (CGM) system.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the requested medication is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy
exception has not been met.
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 Synvisc. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the documentation does not support that
Orthovisc and Monovisc would likely be less effective, and/or would 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 Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc (J7325).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 4, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the services billed.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 80307 and HCPCS G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransurethral waterjet ablation of prostate (0421T).You asked the Plan to pre-approvetransurethral waterjet ablation of prostate (0421T). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services are not covered by Medicare or the Plan.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. Medicare says CPT code 0421T is a Category III code and is considered not medically necessary.Therefore, we decided that the Plan does not have to pre-approvetransurethral waterjet ablation of prostate (0421T).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 205 mile routine transportation trip.
You asked the Plan to pre-approve the 205 mile trip. You say that you need to have this trip approved. The Plan
denied your request. The Plan says your benefit does not cover trips longer than 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve a 205 mile routine transportation trip.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestaff-assisted home dialysis services.You asked the Plan to pre-approvestaff-assisted home dialysis services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says these services are not covered by Medicare and the provider isnot Medicare certified.The Plan must follow Medicare rules. Medicare rules say that staff-assisted home dialysis services are not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvestaff-assisted home dialysis services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you didn't realize the provider was out-of-network. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 September 25, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forradiology services provided to the enrollee on August 18, 2019.You asked the Planto pay forthe services. You say that the enrollee had multiple exams on this date of service.The Plandenied your request. The Plansaysthis claim was not coded correctly.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 codes 72125, 70450, 71045, 72170 are not supported in the medical record. Specifically, these codes appear to be duplicate charges. There is no evidence that these are separate services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forradiology services provided to the enrollee on August 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan (G0297).
You asked the Plan to pre-approve a low dose CT scan (G0297). You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare
criteria.
The Plan must follow Medicare rules. Medicare rules say that LDCT is covered if all of the above criteria are
met.
We looked at the file and Medicare rules. The review shows that the enrollee does not meet the Medicare
criteria requirement of being between the ages of 55 and 77 years. The file shows that the enrollee is 81 years
old. Based on this information, we decided that Medicare rules for coverage of a low dose CT scan (G0297)
have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT scan
(G0297).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99308) provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay fornursing facility care. You say that these services should be covered.The Plan denied your request. The Plan says these services were not authorized.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 forthe nursing facility care (99308) provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care (99307) provided on July 25, 2019. You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized or emergent, there are in-network providers that could have rendered the services at issue.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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forsubsequent nursing facility care (99307) provided on July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient hospital care provided to the enrollee from August 22, 2019 through August 27, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our physician reviewer found the review has determined thatthe treating physician did document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forinpatient hospital care provided to the enrollee from August 22, 2019 through August 27, 2019. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 25, 2019.You asked the Plan to pay for the laboratory services. The Plan deniedyour request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent care and pre-approved care.The requested provider in this case is not a network provider with thePlan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 1, 2019.
You asked the Plan to pay for the services. You say that you were not advised that you were not in-network
with this plan. The Plan denied your request. The Plan says the services were available in-network.
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 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 medical services provided to the enrollee by an out-of-network provider
on October 1, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan.You asked the Plan to pre-approvethe Hyalgan. You say that the records provided support the need for the drug in dispute.The Plan denied your request. The Plan says they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement steptherapy 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 the Hyalgan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs Monovisc and Orthovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. The Plan's required drugs would not likely be less effective and/or likely have adverse effects for the 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 the Hyalgan have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 they are 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services provided on October 2, 2019 by a provider opted-out of participating in Medicare.You asked the Plan to pay forthe dental services. You say that you were not aware the provider opted out of Medicare.The Plan denied your request. The Plan says this provider does not participate with Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met. This provider has opted-out of Medicare. The rules say that Medicare Advantage Plans may not make payment directly or indirectly for Medicare covered services furnished to aMedicare beneficiary by a physician or practitioner who has opted out of Medicare except in cases involving emergency or urgent care services furnished to a beneficiary who has not previously entered into a private contract with the physician or practitioner.Therefore, we decided that the Plan does not have to pay fordental services provided on October 2, 2019 by a provider opted-out of participating in Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from July 21, 2019 through July 24, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.  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 inpatient hospital care. Our physician reviewer found the review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services after the emergency room evaluation. There was no documentation provided necessitating post-stabilization care services at the non-participating facility. The post-stabilization care services were not medically necessary andreasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from July 21, 2019 through July 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Spine (72141).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says an MRI as a requirement prior to a visit does not meet coverage criteria.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found an MRI as a preservice requirement without an interview, exam and assessment by the pain specialist, is not medically reasonable nor 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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Spine (72141).