Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you don't think that there is an innetwork
provider available for these specialty services. The Plan denied your request.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted to an acute care hospital on 02/17/2020 after falling at home and hitting her neck on a
faucet. She required intubation in the emergency department. She went to the operating room for repair of a
neck wound and tracheostomy placement. Hospital course has included treatment for pneumonia and
respiratory failure. The enrollee has grown MRSA and Pseudomonas from her sputum. The enrollee is on
Vancomycin and Cefepime. She has a PEG tube for feeding and a PICC line for intravenous medications. She
also has a history of stroke with right hemiparesis, diabetes, chronic kidney disease and a history of venous
thrombosis and pulmonary embolus. She has been weaned from the ventilator to a tracheostomy mask.
Based on the provided medical records the acute care hospital is able to provide all of the services the enrollee
requires. Based on the provided medical records the enrollee is receiving necessary services and is at an
appropriate level of care in the acute care hospital. Based on the provided medical records the enrollee is
getting these services in the present acute care hospital. Continued care at this level is appropriate until the
enrollee is stable to transfer to a lower level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on November 5, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you did not need to have an office visit to get your colonoscopy results. The Plan denied your request. The Plan says you have been charged the correctcost 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 a $35 copaymentper specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record showsyou received physician services at a specialist's office.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 forthe specialist office visit provided on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).You asked the Plan to pre-approve the bone marrow aspirate. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee is indicated for C7/T1 anterior cervical discectomy and fusion. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the planned cervical spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate is not medically reasonable and necessary for the approved C7/T1 anterior cervical discectomy and fusion.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 bone marrow aspirate have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision of an oral lesion, bone replacement grafting, and the use of biological materials to assist in tissue regeneration.You asked the Plan to pre-approve these dental services. You say that these services are necessary and should be covered.The Plan denied your request. The Plan says the enrollee's dental benefit does not include coverage for these services.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve excision of an oral lesion, bone replacement grafting, and the use of biological materials to assist in tissue regeneration.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialist office visitto be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist office visit. You say that this doctor has been recommended to you.The Plan denied your request. The Plan says you have been approved to see "in network doctor". 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-approvea specialist office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovecompression stockings identified with code A6530, A6533.You asked the Plan to preapprovethe compression stockings. You say that the claim should be paid.The Plan denied your request. The Plan says the stockings are wound care items and are noncovered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530, A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to preapprovecompression stockings identified with code A6530, A6533.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for septoplasty surgery.You asked the Plan to pre-approve physician's services for septoplasty surgery. You say that the enrollee has a nasal mass that has been growing and you need to biopsy the mass. 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 priorauthorization 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 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 services at issue in this appeal. We found no exception that would require thePlan to pre-approve the requested physician's services. Therefore, we decided that the Plan does not have to pre-approve physician's services for septoplasty surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1843, L2397) provided to the enrollee on January 15, 2018.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 andcannot 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 fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1843, L2397) provided to the enrollee on January 15, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided  on April 4,
2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an
office setting, therefore the Place of Service (POS) code 81, indicating an independent laboratory setting, is not
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug test
have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on April 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on November 10, 2019.You asked the Plan to waive the copayment for the ED visit. You say that you were informed that when you return you will not be charged. You say that you were informed it would be a part of your initial visit.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 $120 copayment for emergency care.You have been asked to pay a$63.08, which is less than the standard $120 copayment for the ED visit. The ED visit falls within the "Emergency care" 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 the ED visit provided on November 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you have seen this doctor for 10 years. You say that your doctor referred you. 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 an office visit to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 1, 2019 and billed
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 a decision was not made within the allowed timeframe at the Plan level.
The Plan must follow Medicare rules. Medicare rules say this type of testing is covered based on specific coverage criteria set forth in the LCD. In this case, your appeal states that this service should be covered based on Local Coverage Determination (LCD): MolDX: DecisionDx-Melanoma (L37725). However, this LCD is not in the appropriate jurisdiction for the enrollee or the laboratory location. The enrollee lives in California, the Service Lab is listed as being in Arizona. Neither of these states are jurisdictional for this LCD. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 1, 2019 and billed
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulmonary rehabilitation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve pulmonary rehabilitation. You say that this facility has been specifically requested due to this facility providing pulmonary rehabilitation. The Plan denied your request. The Plan says you have been approved
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 pulmonary rehabilitation to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a head protective helmet.You asked the Plan to pre-approve a head protective helmet. You say that because of your medical condition you have fallen and injured your head.The Plan denied your request. The Plan says protective helmets are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered durable medical equipment.  Based on this information, we decided that Medicare rules for coverage of a head protective helmet have not been met.Therefore, we decided that the Plan does not have to pre-approve a head protective helmet
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist 
You asked the Plan to pre-approve these services. You say that the previous providers did not adequately treat the enrollee's condition. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by physician.You asked the Plan to pre-approve the physician's services to be provided by physician.You say that you have been a patient of this provider for years and you do not want to start all over with another provider. The Plan denied your request. The Plan says you 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization hospital care provided September 6, 2019
You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services were not emergent and there were in-network providers who could provide the service.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 hospital services. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee was stable to be transferred to a plan provider. There were multiple in-network providers within the area. 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 hospital services have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization hospital care provided September 6, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan  does not haveto pay for lab services provided to the enrollee on June 28, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says tests will only be covered and reimbursed that demonstrate analytical and clinical validity at a level that meets the Medicare reasonable and necessary requirement.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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of stage IV retrosigmoid colon cancer. Molecular diagnostic tests performed on the biopsy specimens from the tumor were used to direct therapeutic decisions. The medical records do not reflect a need for additional molecular testing in order to direct further treatment. The enrollee does not meet the criteria for this request.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 have not been met.Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 28, 2019