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

We decided that the Plan does not have to pay for the Guardant360 Biopsy-Free Tumor Sequencing testing panel provided to the enrollee on June 28, 2019.
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. The Plan says these tests are not relevant to this type of cancer.
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 pay for the panel. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the review has determined that the request is not medically necessary under Medicare because Guardant 360 is not FDA approved for use in any cancer other than non-small cell lung cancer, and has no clinical utility in the scope of the enrollee's cancer. The review has determined that the items/services at issue in this case 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 panel have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Biopsy-Free Tumor Sequencing testing panel provided to the enrollee on June 28, 2019.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing on February 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan saysscreening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe genetic testing rendered on February 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewheelchair ramp (E1399).You asked the Plan to pre-approvethe wheelchair ramp. You say that the enrollee is in failing health and finds it extremely difficult to get around. Not having a ramp severely limits her mobility and impacts her quality of life.The Plan denied your request. The Plan says this item is 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 pre-approvewheelchair ramp (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on September 23, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services you provided on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on April 23, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan saysthe denial of payment for these services is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules.Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intentto order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on April 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have blood flow restrictions to both of your legs and open wounds on your feet. Your doctor recommended diabetic shoes so that there is nothing torub your foot against and to add additional protection for the damaged skin on your feet. You say that your doctor does not understand why the requested orthotics would not be covered.The Plan denied your request. The Plan says this item is not a covered benefit.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-approvefoot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429 and A0425) provided on July 11, 2019.You asked the Plan to pay for the ambulance services. You say that the member received two ambulance trips in one day. The Plan denied your request. The Plan says the 76 modifier should be submitted with each additional trip for same day identical ambulance transport.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes A0429 and A0425 are not supported in the record. Specifically, the 76 modifier is required to indicate that a second trip occurred on the same date of service with the same origin/destination. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429 and A0425) provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreeStyle Libre CGM reader and sensors.You asked the Plan to pre-approveFreeStyle Libre CGM reader and sensors. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Therapeutic CGMs and related supplies are covered by Medicare when all of the above coverage criteria are met. In this case, the file does not show that the enrollee has been using a BGM and performing four or more tests per day and the file does not show that the enrollee is insulin-treated with three or more daily injections of insulin or a Medicare-covered CSII pump. Based on this information, we decided that Medicare rules for coverage of FreeStyle Libre CGM reader and sensors have not been met.Therefore, we decided that the Plan does not have to pre-approveFreeStyle Libre CGM reader and sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmological exam provided on October 10, 2019.You asked the Plan to pay for the ophthalmological exam. 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 an ophthalmological exam provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on October 15, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab testing provided on June 17, 2019.
You asked the Plan to pay for the lab testing. You say that the records submitted show that these services were indeed rendered to the patient. The Plan denied your request. The Plan says that the submitted records were not reviewed since the Plan missed the 60-day time frame.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. This claim was denied stating that the billed services were not provided by the facility for the patient. The Plan did not review its original denial rationale on appeal as the 60-day time frame was missed. Based on the information provided, we confirm that there is an order for this testing and a report showing the lab results for this testing. There is no evidence presented that this was furnished by another provider or that the enrollee was not a patient at this facility. Therefore, we decided that the Plan has to pay for the lab testing provided on June 17, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on July 12, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says there is no valid physician order.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 forthe drug testing rendered to the enrollee on July 12, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal surgery (22633) provided on July 26, 2019.
You asked the Plan to pay for spinal surgery. You say that services from this provider were previously
reimbursed. The Plan denied your request. The Plan says this provider has opted out of 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 has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the physician. This provider has opted out of the Medicare program. The file shows that the physician entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for spinal surgery (22633) provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is currently the best available treatment option to prepare the enrollee for a radiofrequency ablation. The Plan denied your request. The Plan says the benefit for this type of procedure has been exhausted.
The Plan must follow Medicare rules. Medicare rules say that five medial branch blocks are covered per rolling 12 month year. 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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for a sixth medial branch block. Repeated medial branch blocks with radiofrequency ablation is not compatible with clinical practice guidelines. The requested procedure 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a medial branch block for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.You asked the Plan to pre-approveadditional services. The Plan denied your request. The Plan says the enrollee can manage the knee problem with a home exercise program.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.The file shows that 24 physical therapy visits were requested. The plan has agreed to pre-approve 12 visits. 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 additional services. Our physician reviewer found that the additional 12 therapy visits in addition to the prior therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee was educated in a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Therefore, the enrollee's current deficits do not require ongoing skilled physical therapy visits beyond what the health plan already approved.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove intermittent limb compression device.You asked the Plan to preapprove intermittent limb compression device. You say that you want the pump to improve circulation in your leg.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for varicose veins or circulation.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file does not show thatenrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to preapprove intermittent limb compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the 2 additional surgical extractions (D7210) provided on August 21, 2019.You asked the Plan to pay the in network rate for2 additional surgical extractions. You say that you contacted the Plan. You say that you were advised that the services would be considered in network.The Plan denied your request. The Plan says 2 surgical extractions are covered per calendar year. The Plan also says that the frequency limit for surgical extractions has been exceeded.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 and surgical extractions are a covered service, the frequency limit of 2 per calendar year has been exceeded.Therefore, we decided that the Plan does not have to pay the in network rate forthe 2 additional surgical extractions (D7210) provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on May 9, 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 there is no valid physician order.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 drug testing rendered to enrollee on May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to enrollee on April 25, 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 there is no valid physician order.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 definitive drug testing rendered to enrollee on April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiovascular services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve cardiovascular services. You say that these services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 cardiovascular services to be provided by an out of network (OON) provider.