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

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessories (E0673) provided on January 5, 2021.
You asked the Plan to pay for a pneumatic compression device and related accessories. You say that the requested items are necessary for use by the enrollee in the home. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 is used only for peripheral artery disease and that, if the base PCD is not covered, related accessories are not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the case record reflects that the requested item is prescribed for prevention of deep venous thrombosis (DVT) or pulmonary embolisms (PE). As prescribed, the requested item is not a covered benefit of Medicare or the Plan. The related accessories coded E0673 are not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessories (E0673) provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia.
You asked the Plan to pre-approve Orencia. You say that the requested Orencia is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Simponi Aria.
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 Orencia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with rheumatoid arthritis. Coverage for treatment with Orencia has been requested. She has failed treatment with multiple other agents. The health plan denied coverage for the Orencia as the plan requires a trial of Simponi Aria before they will approve the requested drug. Based on the medical records provided the enrollee has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has oligometastatic invasive ductal carcinoma of the left breast. She has been treated with letrozole since January of 2015 and has had no evidence of recurrence. Routine imaging for surveillance is not advised, per the National Comprehensive Cancer Network (NCCN) guidelines. The records do not support that the PET scan is reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and CT of
the pelvis (74174).
You asked the Plan to pre-approve the CT scan. You say that you would like to perform another CTA rather
than a plan CT as you are looking for progression of the existing AAA. The Plan denied your request. The Plan
says the records do not support that the requested CTA is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee was seen in the ED on 07/04/19 with abdominal pain. A bedside aorta ultrasound
was performed which showed an unremarkable abdominal aorta less than 4 cm, but the view was complicated
by bowel gas and body habitus. A CTA was also performed on 07/04/19. The Guidelines support a CTA every
3 years for follow up on AAA. A standard CT could be done in the interim. The review has determined that the
requested CTA of the abdomen and pelvis is 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and CT of the pelvis (74174).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care (99220) and observation care discharge day management (99217) provided November 5, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the initial observation care and observation care discharge day management. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no medical records have been received for these services.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the initial observation care (99220) and observation care discharge day management (99217) provided November 5, 2020, by an out-of-network (OON) provider.
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 the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient does not require treatment by multiple therapies and there are no complex
nursing or rehabilitation needs.
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. Specifically, medically necessary services are
available at a lower level of care. This means admission into an IRF is not medically necessary. 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 copayment for a diagnostic mammogram provided on
September 4, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was a routine
mammogram, and you should not owe a 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 the Plan clearly says that you must pay a $40
copayment for routine radiology and diagnostic services.
The medical records show that you received a diagnostic mammogram on September 4, 2020. Therefore, you
are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram 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 copayment for a diagnostic mammogram provided on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve the massage therapy. You say that you need this therapy. The Plan denied your request. The Plan says massage therapy is not medically necessary under Medicare.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 64 additional routine transportation trips.
You asked the Plan to pre-approve 64 additional routine transportation trips. You say that you have cancer and cannot get to your appointments without transportation. The Plan denied your request. The Plan says your transportation benefit has been exhausted.
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 a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 64 additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the laboratory services are not supported in the medical record. Specifically, these services should
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the
comment/narrative field.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continued SNF care. You say that the records provided support the need for continued SNF care. The Plan denied your request. The Plan says there are no further skilled nursing or skilled therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records provided do not show that the enrollee requires skilled nursing services. The medical records provided do show that the enrollee requires skilled therapy services. However, the skilled therapy service needs are not required on a daily basis. The enrollee does not require the needed services on an inpatient basis, only in a SNF setting. Services in the home or an assisted living facility with home health care, or in a long-term care facility on a part-time basis appear appropriate 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 the continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 22, 2021.
You asked the Plan to waive the copayment for the office visit. The Plan denied your request. The Plan says the copayment 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 a $20 copayment for each Medicare-covered specialist visit.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was at a specialist's office. 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 the office visit provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9940) to prevent teeth grinding.
You asked the Plan to pre-approve the mouth guard. You say that this item is necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9940) to prevent teeth grinding.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on December 1, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to pay for this since you went to the emergency room from the urgent care center. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was provided, the correct copayment has been applied. An emergency room visit falls within the emergency care 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 emergency room visit provided by a participating provider on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
You asked the Plan to pre-approve an MRI, any joint of lower extremity; without contrast material (73721). You say that the enrollee has knee pain and needs an MRI. The Plan denied your request. The Plan says an MRI is not indicated for knee arthritis.
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 an MRI, any joint of lower extremity; without contrast material (73721). Our reviewer says that an MRI is not medically reasonable and necessary. Our physician reviewer found no physical findings or other objective information suggested a need for MRI, which would not significantly change the treatment plan for this patient or the outcome. Therefore, this request for MRI will be considered not 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 an MRI, any joint of lower extremity; without contrast material (73721) have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency transport (A0427RH) and the emergency transport (A0428HH) provided from October 18, 2020, to November 5, 2020.
You asked the Plan to waive the copayments for the transportation services. You say that you called the ambulance because you were unable to breathe. You say that you were deemed to have had a heart attack and heart failure. You say that you were provided transportation from the hospital to the rehabilitation center. You also say that you were not informed that providing your own transportation was an option. The Plan denied your request. The Plan says the $100 copayment was applied correctly to each date of service. The Plan says that the Evidence of Coverage clearly states that there is a $100 copayment for ambulance transportation.
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 $100 copayment after the yearly deductible has been met for Ambulance Services.
You have been asked to pay the 2 $100 copayments for the transportation services. The transportation services fall within the Ambulance 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 copayments for the emergency transport (A0427RH) and the emergency transport (A0428HH) provided from October 18, 2020, to November 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be cared for at home. The Plan
denied your request. The Plan says the enrollee is stable and can return home.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 submitted medical records do not show that the enrollee has skilled nursing needs. While the records do support that the enrollee has skilled therapy needs, they do not show that the enrollee needs therapy services on a daily basis. Based on the medical records provided this patient does not require the services on 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-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for dialysis.
You asked the Plan to pre-approve the referral. You say that this is medically necessary, as you would like to go a dialysis center closer to home. The Plan denied your request. The Plan says care must be received in the primary 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 out-of-network for dialysis.