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

We decided that the Plan does not have to pay fortesting services provided to the enrollee on August 21, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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. 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 fortesting services provided to theenrollee on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefacet joint injections for the enrollee.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation showing that PT is contraindicated.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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of recent conservative therapy. You have declined PT or a brace. The request does not meet the criteria of the LCD, and therefore, is considered 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 injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approvefacet joint injections for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on September 12, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 services at issue in this appeal. 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 forphysician services provided to the enrollee on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are losing your muscle strength and need to improve your mobility. The Plan denied your request. The Plan saysyou can safely receive the necessary care in another setting.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of careWe 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve this equipment.a protective outer surface covering (L5964).You asked the Plan to pre-approve this equipment.the covering. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there is no documentation that supports that the member's activity subjects him to harsh environmental situations or that he engages in any extraordinary activities that would justify the need for extra protection.The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis.We asked our physicianreviewer 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 covering. Our reviewer says that this cover is not medically reasonable and necessary. Our physician reviewer found the documentation does not support that the member has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by the already approved cover.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 covering have not been met.Therefore, we decided that the Plan does not have to pre-approve this equipment.a protective outer surface covering (L5964).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveoutpatient nutritional counseling.You asked the Planto pre-approvemedical nutrition therapy services. You say that this is medically necessary.The Plandenied your request. The Plansaysthese services are not covered a benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plandoes not haveto pre-approveoutpatient nutritional counseling.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forPost-Stabilization inpatient care provided July 2 to July 5, 2019. You asked the Plan to pay forthe inpatient services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network facility.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 inpatient services. Our reviewer says that coverage criteria was not met. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility for observation/admission level of care services after the emergency room evaluation. There was no documentation provided necessitating post-stabilization care services at the non-plan facility.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 inpatient services have not been met.Therefore, we decided that the Plan does not have to pay forPost-Stabilization inpatient care provided July 2 to July 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on November 4, 2019.You asked the Plan to pay forthe panoramic x-ray. You say that you are requesting a reconsideration of the Plan's denial for payment as you have only received this service once previously.The Plan denied your request. The Plan says that full mouth x-rays are covered once every three years.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. We looked at the case fileand the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-ray havenot been met.Specifically, you have exceeded the frequency limit allowable as you have received this service previously on May 17, 2017.Full mouth x-rays are coveredonce every three years under your contractual policy.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Revitive blood circulation machine.You asked the Planto pre-approvethe machine. You say that this is medically necessary.The Plandenied your request. The Plansaysvery little clinical information was received about the illness.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 machine. Our reviewer says that the requested machine isnot considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for using this device. The review has determined that the requested Revitive Blood Circulation Machine is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the machine have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Revitive blood circulation machine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the chest.You asked the Plan to pre-approveCT scan. You say that your doctor feels that you need this CT scan.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because previous CT scans show your lung nodule is stable and further work-upis not needed at this time.The Plan must follow Medicare rules. Medicare rules say that CT 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 wascorrect in denying the request to pre-approve CT scan. Our reviewer says that you do not meet the Medicare criteria for the requested CT scan. Our physician reviewer found a previous CT scan showed your lung nodule to be stable. There is no evidence of symptoms or objective findings to explain why another CT scan is currently being requested. Therefore, the documentation submitted does not support that this CT scan is medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOneTouch Verio test strips for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the supplies are available from the preferred brand.The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred durable medical equipment and supplies providers.We looked at the file and Medicare rules. The requested OneTouch Verio test strips are not from the preferred provider for the Plan. Diabetic testing strips are available from ACCU-CHEK and Trividia.Therefore, we decided that the Plan does not have to pre-approveOneTouch Verio test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay formoderate sedation services provided to the enrollee on June 14, 2019.You asked the Planto pay forthe services. You say that thisshould be paid for.The Plandenied your request. The PlansaysCurrent Procedural Terminology (CPT) code 99152 remains not supported, as the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15minutes of intraservice time, patient age 5 years or older."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 supported by the medical records submitted. Our physician reviewer found while the enrollee underwent an interventional cardiac catheterization on 6/14/2019, there is no documentation as to what sort of sedation was provided, who provided that sedation or who monitored the duration of the sedation. Therefore, the billing of CPT 99152 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 services have not been met.Therefore, we decided that the Plandoes not haveto pay formoderate sedation services provided to the enrollee on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechiropractic services.You asked the Plan to pre-approvethe chiropractic services. You say that you would like reconsideration because your back becomes twisted and you would like chiropractic services.The Plan denied your request. The Plan says you do not have subluxation and have been diagnosed with sciatica.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 pre-approve the chiropractic services Our reviewer says that there are no submitted imaging studies to reveal evidence of a subluxation. Our physician reviewer found the submitted office visit note reveals findings of trochanter bursa not tender, negative straight leg raise, stable gait and muscle tone and strength normal throughout, with a diagnosis of sciatica.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 chiropractic services have not been met.Therefore, we decided that the Plan does not have to pre-approvechiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespinal cord stimulatortrial. You say that the enrollee is established with this provider and you feel it is unfair for the enrollee to change providers.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.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 carefrom 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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep study for the enrollee.
You asked the Plan to pre-approve the sleep study. The Plan denied your request. The Plan says the previous sleep study was able to show the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that outpatient sleep studies 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 sleep study. Our physician reviewer found that the enrollee had a diagnostic attended PSG on October 25, 2019, that did not show obstructive sleep apnea (OSA). The AHI was well within normal limits at 1. The sleep duration was adequate for diagnosis. This essentially excludes obstructive sleep apnea. A home sleep test would be less sensitive than the attended study that was already performed, in the diagnosis of OSA. Because the enrollee has already had an adequate PSG, a repeat study at home is not reasonable or 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep study for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMedtronic Guardian #3 sensors and transmitter.You asked the Plan to pre-approveMedtronic Guardian #3 sensors and transmitter. You say that the enrollee has been on an insulin pump for many years and the Medtronic Guardian sensor and transmitter would assist in management for a complex medical issue.The Plan denied your request. The Plan says Medicare does not cover non-therapeutic continuous glucose monitoring systems or supplies.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Non-therapeutic continuous glucose monitors and supplies are not coveredby Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of Medtronic Guardian #3 sensors and transmitter have not been met.Therefore, we decided that the Plan does not have to pre-approveMedtronic Guardian #3 sensors and transmitter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on December 16, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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. 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 forlab services provided to the enrollee on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea dental CT scan (D0367).You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 itemsor services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvea dental CT scan (D0367).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to a medical appointment in
your state (trip of between 77 and 85 miles).
You asked the Plan to pre-approve the routine transportation trip. You say that you need to get to this
appointment and have no other means of getting there. The Plan denied your request. The Plan says your
routine transportation benefit does not cover trips of over 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. The file shows that the requested trip
exceeds 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine
transportation to a medical appointment in your state (trip of between 77 and 85 miles).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransmitter, external for use with interstitial continuous glucose monitoring (A9277).You asked the Plan to pre-approvethe transmitter. The Plan denied your request. The Plan says that this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and code A9277 is used to describe the supplies used with a non-therapeutic CGM.We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies.Therefore, we decided that the Plan does not have to pre-approvetransmitter, external for use with interstitial continuousglucose monitoring (A9277).