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

We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
You asked the Plan to pre-approve the PET scan. You say that the requested service is needed to know where the cancer is and how much of it has grown. You say that the requested PET scan will allow treatment to be started in order to save the enrollee's life. The Plan denied your request. The Plan says PET imaging is not supported for routine follow-up of the clinical condition presented. The Plan says that the clinical information provided does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested PET scan is not medically reasonable and necessary. Our physician reviewer found the enrollee is being monitored for recurrence of disease. A PET scan is not a standard imaging modality for surveillance in patients with esophageal adenocarcinoma. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the Part B step therapy criteria were not 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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the plan requires prior treatment failure with the preferred alternatives Durolane, Gelsyn-3 and Synvisc/Synvisc-One prior to approval of the requested medication. The documentation submitted includes chart notes. Chart notes do not support that the enrollee has had prior treatment with Durolane, Gelsyn-3, or Synvisc/Synvisc-One. The prescriber does not state why the alternatives required by the Plan (1) would not be as effective for the enrollee as the requested drug; and/or (2) would have adverse effects for the enrollee. Therefore, an exception to the Plan's step therapy criteria is not supported.
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 Euflexxa injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December
16, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that the ambulance services were
not necessary as you could have taken yourself to the emergency room. 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 $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the
ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services
provided on December 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozepmpic.
You asked the Plan to pre-approve Ozepmpic. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Ozepmpic.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the continuation of SNF is not medically necessary.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided from August 22, 2019 to September 3, 2019. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 services provided Our physician reviewer found that the submitted imaging report of the cervical spine revealed facet arthrosis throughout the spine, most notable at C5 and C6. The thoracic spine report revealed vertebral body spurring throughout the spine, most notable at T4-T7 and moderate kyphosis. These findings do not reveal evidence of a subluxation. The submitted chart notes/office visit notes for the dates of service in question, mainly, reveal findings of subluxations/chiropractic treatment listings and a range of motion notation or two. These findings do not reveal evidence of subluxation per Medicare guidelines. In addition, the x-ray findings reveal degenerative/arthritic type findings, which are clearly chronic, for which chiropractic can do little. The submitted notes reveal some 17 chiropractic treatments and three actual chart notes. The chart notes reveal little evidence of significant improvement, with little evidence and little likelihood that further clinical improvement has or will occur with any additional chiropractic treatments. Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines. 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from August 22, 2019 to September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 21, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the doctor didn't read your information. You say that money should be given to someone who deserves it. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you received services during the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 5, 2019.
You asked the Plan to pay for the services provided. You say that the codes are supported by the physician custom profile. The Plan denied your request. The Plan says the records submitted upon appeal appear to have been altered.
The Plan must follow Medicare rules. Medicare rules say that amendments corrections, or addenda must clearly identify any amendment or correction.
We find that the original custom toxicology profile is different than the profile submitted on appeal. There is no clear identification of an amendment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from February 4, 2020 through March 9, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were informed there was no charge for the service. You say that you shouldn't be responsible. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare covered physical therapy visits. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $400 ($40/visit x 10 visits = $400). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from February 4, 2020 through March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator provided on
December 5, 2019.
You asked the Plan to waive the coinsurance for the bone growth stimulator. You say that you were told there
would be no charge. You say if you had known it was going to cost $700, you would not have gotten it because
you are on a very limited income. The Plan denied your request. The Plan says you have been charged the
correct cost sharing 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 20%
coinsurance for Medicare-covered items.
You have been asked to pay $744.51 which is 20% of the allowed amount for the bone growth stimulator. The
allowed amount is $3,722.53. ($3,722.53 x 20% = $744.51). The bone growth stimulator falls within the
"Durable medical equipment (DME) and related 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 coinsurance for the bone growth stimulator provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 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 an office visit provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on July 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that you cannot use standard diabetes testing strips with your hands. The Plan denied your request. The Plan says that a CGM is not covered if you are not on insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
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 enrollee requires IRF level of care. The Plan
denied your request. The Plan says the enrollee does not meet the criteria for an admission to an IRF. This
request cannot be approved because care in an IRF exceeds member's medical needs.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does require skilled physical therapy and occupational therapy but based on the medical records provided the
enrollee does not require treatment in an intensive rehabilitation therapy program. There is concern that the
enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility. A lower level of care would be more appropriate.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel surgery. 
 
You asked the Plan to pre-approve the carpal tunnel surgery. You say that the records provided support the need for the requested surgery. The Plan denied your request. The Plan says the requested surgery is not medically reasonable and 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 the carpal tunnel surgery. Our reviewer says that carpal tunnel surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of conservative measures to include 6 weeks of splinting or a steroid shot. 
 
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 carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for molecular pathology services. You say that you are the only company that can provide these tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 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 molecular pathology services provided on August 28, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing and skilled physical therapy home health services.
You asked the Plan to pre-approve skilled nursing and skilled physical therapy home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing and skilled physical therapy home health services. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found that you do not have skilled nursing needs such as IV antibiotics, new enteral feedings, complex wound care. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. You have had prior therapy and was instructed in a home exercise program. The documentation does not support that ongoing skilled therapy services are 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 skilled nursing and skilled physical therapy home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing and skilled physical therapy home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination provided on December 3, 2019.
You asked the Plan to pay for the radiologic examination. The Plan denied your request. The Plan says nonemergent,
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 radiologic examination provided on December 3, 2019.