Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facial feminization surgery and mammaplasty augmentation for the enrollee.
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says purely cosmetic procedures are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedures. Our reviewer says that the requested procedures are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been receiving gender-affirming hormone therapy. The clinic follow-up notes dated 11/6/19 documents a fair amount of breast tissue, and normal symmetry. On 1/20/20, the HENT exam is documented as normocephalic and atraumatic. The medical records do not support a positive determination for 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 procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve facial feminization surgery and mammaplasty augmentation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epifix wound care services for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the longer the wound is open, the greater the chance of infection. The Plan denied your request. The Plan says the wound is secondary to the performing of a skin biopsy.
The Plan follows Medicare rules. Medicare rules say that the use of amniotic membrane derived skin substitutes are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee had a skin graft on January 31, 2020. Progress notes indicate the wound continued to slowly improve. There was no documented concern for infection. The documentation does not support the enrollee has a diabetic skin ulcer or venous stasis ulcer. Review of the literature supports the use of bioengineered skin substitutes for diabetic wounds. The guidelines are note supported by the records. Therefore, the requested services are not medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve Epifix wound care services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 17, 2019 by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 urgentcare 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 atissue. 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 medical services provided on September 17, 2019 by a non-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from November 23, 2019 to November 30, 2019.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from November 23, 2019 to November 30, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approverevision of bariatric surgery using the ROSE procedure.You asked the Plan to pre-approverevision of bariatric surgery using the ROSE procedure. You say that the requested revision of bariatric surgery using the ROSE procedure is medically necessary.The Plan denied your request. The Plan says the requested revision of bariatric surgery using the ROSE procedure is not medically necessary.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 revision of bariatric surgery using the ROSE procedure. Our reviewer says that the requested revision of bariatric surgery using the ROSE procedure is not medically necessary. Our physician reviewer found the enrollee is 6 feet 1-inch-tall, weighs 266 pounds giving a body mass index of 35.09 kg/m2. The enrollee is status post gastric bypass procedure 15 years ago with 50-pound weight regain. The requested procedure in this case is considered investigational for treatment of weight regain as it has failed to demonstrate durable long term weight loss outcomes.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revision of bariatric surgery using the ROSE procedure have not been met.Therefore, we decided that the Plan does not have to pre-approverevision of bariatric surgery using the ROSE procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 18, 2019.
You asked the Plan to pay for the nurse practitioner 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 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 nurse practitioner services provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and wrist hand finger orthosis provided on November 21, 2019.
You asked the Plan to pay for the knee orthosis (L1833) and wrist hand finger orthosis (L3807). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include an itemized delivery ticket and the medical documentation did not support medical necessity.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the knee orthosis and wrist hand finger orthosis provided on November 21, 2019.
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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer 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 based documentation provided, you are undergoing treatment for sepsis and chronic constipation. You were intubated/ventilated and subsequently received a tracheotomy. As acute care hospitals and long-term acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring you from the current facility. Medicare coverage criteria for transfer to an LTACH 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the 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 providersavailable 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 forthe medical services provided to the enrollee by an out-of-network provider on June 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on November 9,2019 to enrollee by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 referring provider 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 laboratory services provided on November 9, 2019 to enrollee by a non-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).You asked the Plan to pre-approve the Hyalgan. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.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 the Hyalgan. Our reviewer says that the member has not tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective or have adverse effects. 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-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation.
You asked the Plan to pre-approve cooled radiofrequency ablation. You say that this is the preferred method for radiofrequency lesioning. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered. We looked at the file and Medicare rules. The record indicates that the requested procedure will use low grade thermal energy (<80 degrees Celsius). This is not covered under Medicare rules Based on this information, we decided that Medicare rules for coverage of cooled radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on November 7, 2019 to November 14, 2019.
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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the home infusion therapy rendered to the enrollee on November 7, 2019 to November 14, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0427 and A0425) provided on October 21, 2019.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim was submitted without a valid secondary diagnosis code.
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 ambulance services are supported in the record. Specifically, per Medicare, diagnosis code Z74.3 is a valid code and has been included in addition to the primary diagnosis. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for ambulance services (A0427 and A0425) provided on October 21, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Vertiflex spacer is considered experimental/investigational in nature, as more research is needed to determine efficacy. The Vertiflex spacer is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided by a specialist on October 30, 2019.
You asked the Plan to waive the copayment for a duplex scan. You say that the services were provided by your primary care physician. 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 $0 copayment for outpatient diagnostic tests provided by a primary care physician and a $50 copayment when provided by a specialist. The record shows that you received a duplex scan from a specialist on October 30, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a duplex scan. A duplex scan 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 duplex scan provided by a specialist on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided by on June 9, 2019.
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for genetic testing provided on June 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for replacement Zinc air battery (L8621) services provided on
September 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the replacement Zinc air battery. You say that there is no provider within your
network which is why you have to order out of network. You had called and was assured that you would have
no trouble submitting a request form for payment. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider. The plan says that non-emergent services with noncontracted
providers require prior-authorization prior to services being rendered.
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 replacement Zinc air battery (L8621) services
provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided by out of network provider (OON) on November 6, 2019.You asked the Plan to pay forthe non-emergent ambulance service. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says you did not request 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 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 forthe ambulance service provided by out of network provider (OON) on November 6, 2019.