Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is an in-network provider that can provide the requested service.
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 to an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance was called for you because it was believed that you would need to go to the hospital. However, you say that after the responders arrived and evaluated you, it was discovered that you were not actually having a stroke. You stated that you were feeling better and so it was decided that you would not go to the hospital. You say that it is unfair for the Plan to deny payment since you did not know that you would eventually not be transported. You asked the Plan to reconsider providing payment for the services. 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 February 27, 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 while the enrollee does have skilled nursing and skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 admission to a Skilled Nursing Facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 17, 2019.
You asked the Plan to pay for the ambulance transport from dialysis. You say that the transport was medically necessary. The Plan denied your request. The Plan says the enrollee could have been transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport from dialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria were not met. The denial is upheld. 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 ambulance transport from dialysis have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zofran tab 8mg for the enrollee.
You asked the Plan to pre-approve the tab. You say that this is medically necessary. The Plan denied your request. The Plan says this may be covered under the pharmacy benefit, but it does not appear the enrollee's pharmacy benefit is with this plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zofran tab 8mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation services (99153) provided on March 4, 2020.You asked the Plan to pay forthe moderate sedation services. You say that you would like reconsideration because this service will billed with the correct place of service code.The Plan denied your request. The Plan says CPT code 99153 is a technical component only code and therefore not payable when billed with place of service code 22.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility and may only be billed by the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay formoderate sedation services (99153) provided on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen (J1459).You asked the Plan to pre-approve the Privigen. The Plan denied your request. The Plan says Privigen is not medically necessary for long term treatment of the enrollee's diagnosis.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 Privigen. Our reviewer says that Privigen does not meet the Plan's coverage criteria. Our physician reviewer found while Privigen is indicated for the treatment of several autoimmune disorders, it does not have an indication for use in treating autoimmune thyroiditis or autoimmune encephalitis. Our reviewer found that while some studies have shown promise in using Privigen to treat autoimmune encephalitis, these studies are a work in progress and the number of patients studied is small. Our physician reviewer also found that the documentation does not show the request 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 Privigen have not been met.Therefore, we decided that the Plan does not have to pre-approve Privigen (J1459).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in hypoglycemic respiratory failure, and unable to wean. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for sepsis in the setting of aspiration, dementia and failure to thrive. The enrollee is not intubated/ventilated. The enrollee is noted to have a poor prognosis wither terminal disease trajectory. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you received a notice stating that the services had not been paid. You asked the Plan to reconsider paying for the services. 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 March 10, 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.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvefoot/nail care to be requested from an out of network (OON) provider.You asked the Planto pre-approvethe OON foot/nail care. You say that the enrollee has nail issues and is prone to gangrene and has needed amputation in the past due to this. Nail care cannot be put off and it is necessary for this to be provided in her facility.The Plandenied your request. The Plansaysthatthis was denied since there is no OON coverage. The enrollee can be seen by a network provider as scheduled.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. The rules also say that plans must arrange out of network care if necessary services are not available in-network.The Plan hasnot made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan failed to positively identify any network providers able to treat the enrollee while quarantined in her nursing facility. The Plan included some mention of asking the medical group to find a provider able to see her in the facility, but no documentation was submitted showing that one was found. Maximus faxed a request for information on July 10, 2020 asking for confirmation regarding whether a suitable network provider had be located, but no response was received. Without some documentation that the Plan's network was able to provide this service, we find that OON care must be arranged.Therefore, we decided that the Planhas to pre-approvefoot/nail care to be requested from an out of network (OON) provider.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen 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 the drug testing services provided on October 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fitting of spectacles (92340) provided on March 17, 2020.You asked the Plan to pay forthe fitting of spectacles. You say that this was medically necessary.The Plan denied your request. The Plan says this was not a covered service.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 92340 is not supported in the medical record. Specifically, this code has a status code of N, indicating that it is not a covered service. Based on this information, we decided that Medicare rules for coverage of the fitting of spectacles have not been met.Therefore, we decided that the Plan does not have to pay forthe fitting of spectacles (92340) provided on March 17, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve weekly skilled nursing visits in the home health setting beyond April 17, 2020.
You asked the Plan to pre-approve the weekly home health services. You say that the enrollee has a medical need for weekly visits with a home health nurse to maintain her condition. The Plan denied your request. The Plan says that the documentation does not support that continued home health services are medically necessary in this case.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan has to pre-approve weekly skilled nursing visits in the home health setting beyond April 17, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (J7321).
You asked the Plan to pre-approve Supartz. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy criteria have 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 Supartz. Our reviewer says that the
criteria for coverage of Supartz have not been met. Our physician reviewer found the Plan requires a trial of
Orthovisc and Monovisc before they will approve the requested drug. There is no evidence that the enrollee is
allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried
and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why
these other forms of hyaluronic acid would not be expected to be safe and effective 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 Supartz have not been met. Therefore, we decided that the Plan does not have to
pre-approve Supartz (J7321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile testing provided to the enrollee on October 30, 2019.
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 this testing must be reported with CPT 81479.
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile testing provided to the enrollee on October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the Brain (70551) provided February 16, 2020.
You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $200 copayment for outpatient diagnostic services. You have been asked to pay a $200 copayment for the MRI. The MRI falls within the outpatient diagnostic 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 magnetic resonance imaging (MRI) of the Brain (70551) provided February 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot inserts for shoes for the enrollee.You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary.The Plan denied your request. The Plan says the requested item must be on a shoe that is an integral part of a covered brace.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve custom foot inserts for shoes for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT Scan of the upper spine (72125) provided on August 6,
2019.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because the member
was told they would be reimbursed for this service. The Plan denied your request. The Plan says the member
was therefore notified of the authorization denial prior to the service being rendered.
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not
covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CT Scan have not been met. Specifically, the record indicates that the member was informed
that this service would not be covered prior to the CT Scan being rendered. Therefore, we decided that the Plan
does not have to pay for a CT Scan of the upper spine (72125) provided on August 6, 2019.