Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve the Clarifix device.

You asked the Plan to pre-approve the Clarifix device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says that there is insufficient evidence to assess the safety and/or impact of this device on health outcomes.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Clarifix device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found ablating the Vidian nerve is not experimental and is considered the standard of care for surgical treatment of vasomotor rhinitis.

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 Clarifix device have been met. Therefore, we decided that the Plan has to pre-approve the Clarifix device.

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 a respiratory viral panel (87631).

You asked the Plan to pay for a respiratory viral panel. You say that this was reported correctly. The Plan denied your request. The Plan says this is not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that that a multiplex PCR respiratory viral panel service is covered under limited circumstances. One of the diagnosis codes listed in the Local Coverage Article must be on the claim in addition to the sign or symptom for which there is suspicion of respiratory illness.

We looked at the file and Medicare rules. The testing at issue was not billed with a diagnosis code that supports medical necessity. Based on this information, we decided that Medicare rules for coverage of a respiratory viral panel have not been met. Therefore, we decided that the Plan does not have to pay for a respiratory viral panel (87631).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac gene panel.

You asked the Plan to pay for the testing services. You say that the results of the testing allow physician to make treatment decisions for the enrollee. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

In this case, there are insufficient medical records to show the testing services were ordered for a specific treatment strategy or diagnosis. The testing services were requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac gene panel.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records show you do not require skilled nursing or therapy services on a daily basis. Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services.

You asked the Plan to pay for the psychiatric diagnostic evaluation with medical 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 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 a psychiatric diagnostic evaluation with medical services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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 the claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered.
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 were weak and got better soon. 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. 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: 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 IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met.

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 based on the
medical records, you do not require the intensity of services provided at an IRF. Specifically, the records do not
show that you require fifteen hours per week of rehabilitative services and regular physician evaluation.
Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.
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 reduce the copayment for the x-ray of the hip you had with a radiology specialist.
You asked the Plan to reduce the copayment for the x-ray of the hip. You say that you believe you should only have a $15 copayment. You say that your doctor could not do the x-ray, so you had to have it done at a different location. The Plan denied your request. The Plan says the provider who performed the x-ray is a radiologist, which is a specialist. Therefore, the Plan says that you were charged this copayment 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 $45 copayment for basic radiological services with a specialist. You have been asked to pay a $45 copayment for the x-ray of the hip. The radiologist who performed this service is a specialist. 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 reduce the copayment for the x-ray of the hip you had with a radiology specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power mobility equipment from an out-of-network
provider.
You asked the Plan to pre-approve out of network providers. You say that this equipment is medically
necessary. The Plan denied your request. The Plan says this equipment can be provided 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 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 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 power mobility equipment
from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the alcohol wipes coded A4245.

You asked the Plan to pay for the alcohol wipes. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 A4245 is alcohol wipes, per box. 

We find that CPT code A4245 is not supported in the medical record. Specifically, this code has an indicator of "N". This means that these items are paid under outpatient prospective payment system (OPPS) and payment is packaged into payment for other services. There is no separate payment for these items. Based on this information, we decided that Medicare rules for coverage of the alcohol wipes have not been met. Therefore, we decided that the Plan does not have to pay for the alcohol wipes coded A4245.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for FoundationOne Liquid CDx.

You asked the Plan to pay for the FoundationOne Liquid CDx. You say that you would like reconsideration because this is a Medicare approved benefit that was ordered by the member's treating physician. The Plan denied your request. The Plan says that this testing was not ordered by the treating physician.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the FoundationOne Liquid CDx. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found NGS was used to guide treatment decision making. NGS has become a standard of care. He appears to meet the criteria for coverage with refractory recurrent cancer and no prior testing.

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 FoundationOne Liquid CDx have been met. Therefore, we decided that the Plan has to pay for FoundationOne Liquid CDx. Please note, the record indicates that this testing was ordered by the member's treating physician.

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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided out of network.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says these services are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. A licensed marriage family therapist is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided out of network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (group 3 standard, multiple power
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds) (CPT code K0861) and
accessory power seating system, tilt (CPT Code E1002), for the enrollee.
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The
Plan denied your request. The Plan says the guidelines for coverage of the requested items have not been met.
The Plan says that the enrollee does not have a qualifying diagnosis for coverage of the requested items.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 DME. Our physician reviewer
found based on the medical records provided there is no documentation that the criteria for coverage of the
requested group 3 power wheelchair and a power seat tilt have been met. Records do not document that the
enrollee has a mobility limitation that significantly impairs his ability to participate in one or more mobilityrelated
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in
customary locations in the home (as required under section A of the LCD). The provided records only address
mobility limitations in the enrollee's workplace, not in his home.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve a power wheelchair (group 3 standard, multiple power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds) (CPT code K0861) and accessory power seating system, tilt
(CPT Code E1002), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).

You asked the Plan to pre-approve Botox. You say that you would like reconsideration because you have
attempted other options that are either not available or unsuccessful. The Plan denied your request. The Plan
says Botox is considered investigational for the treatment of your condition.

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 Botox. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no agreement whether botulinum toxin can effectively relieve the symptoms and
improve the results of gastric emptying study in patients with gastroparesis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 short-term acute care hospital can provide for all of the enrollee's current care needs. The enrollee is receiving an appropriate level of care in the present setting. Medicare coverage criteria for transfer are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received from an outpatient hospital facility.

You asked the Plan to waive the copayment for the lab services. You say that you believe you are being taken advantage of with this billing. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for lab services at an outpatient hospital facility.

You have been asked to pay a $10 copayment for the lab services. The facility where you received these lab services is considered an outpatient hospital facility. 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 services you received from an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 26, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's 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 physician's services provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGM.

You asked the Plan to pay for the CGM. 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 CGM. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the air filters provided on October 14, 2020.
You asked the Plan to pay for the air filters. You say that your physician told you to use air cleaners for your asthma. The Plan denied your request. The Plan says the items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the air filters provided on October 14, 2020.