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

We decided that the Plan does not have to pre-approve Prolia injections.You asked the Plan to pre-approve Prolia injections. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested injections are not medically necessary.The Plan follows Medicare rules. Medicare rules say that Prolia injections are only covered for certain 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 Prolia injections. Our reviewer says that the documentation does not support that the requested Prolia injections are medically reasonable or necessary. Our physician reviewer found the enrollee has osteopenia on Dexa scan. The documentation supports that the enrollee had a score 7 years ago that was in range that would necessitate use, but current study does not appear to meet osteoporosis criteria. The documentation does not support any vertebral fractures or any other sign of injury. Therefore, the enrollee does not meet criteria for the requested 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 Prolia injections have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 8, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 Plandid not pre-approve the servicesat 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 August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCardioMEMS..You asked the Plan to pre-approveCardioMEMS. 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. 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 CardioMEMS. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of nonischemic cardiomyopathy (ejection fraction 40-45%) and congestive failure requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMSdevice has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Therefore, the enrollee does not meet criteria for the requested services.Review of the file shows that the plan uses Local Coverage Determination, LCD L36419 to support their denial. However, LCD L36419 is not valid for the enrollee's home state. Therefore, we cannot use LCD L36419 to substantiate our decision.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met.Therefore, we decided that the Plan does not have to pre-approveCardioMEMS.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of anesthetic agent, sympathetic nerves.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no records showing complex regional pain syndrome.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested injection of an anesthetic agent/sympathetic nerve block is not indicated for the submitted diagnosis of trigeminal neuralgia. The review has determined that the services at issue in this case are not medically reasonable and necessary. Regional sympathetic nerve blockade has been utilized primarily for the treatment ofcomplex regional pain syndrome.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 Plandoes not haveto pre-approveinjection of anesthetic agent, sympathetic nerves.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 31, 2019 by out of network provider.You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted.The Plan deniedyour request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the member's health plan, and the member self-directed.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 forthe medical services provided on May 31, 2019 by out of network provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional LogistiCare mileage.You asked the Plan to pre-approve additional LogistiCare mileage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you are asking for a total of 75 miles per one-way trip to your destination. The Plan says your contract clearly states you are only covered for up to 50 miles per one-way trip.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 a maximum of 48 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are asking for a total of 75 miles per one-way trip to your destination. Your contract clearly states you are only covered for up to 50 miles per one-way trip.Therefore, we decided that the Plan does not have to pre-approveadditional LogistiCare mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture office visits/adjustments.You asked the Planto pre-approve the adjustments. You say that acupuncture has been remarkably helpful.The Plan denied your request. The Plansaysacupuncture is not intended to be a long term or stand-alone treatment for pain relief.The rules say that acupuncture servicesare not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture only when the services are medically necessary and reasonable. 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 adjustments. Our reviewer says that the requested adjustments are not medically reasonable or necessary. Our physician reviewer found the progress notes submitted for review do not describe the acupuncture treatments and the duration and degree of pain relief achieved. Rather, you are on 75mcg of Fentanyl and Hydrocodone (greater than 100 Morphine Equivalent per day), without opiate maintenance agreement or urine toxicology submitted for review. There is no detail as to how you have increased functioning. The request for additional acupuncture visits is not supported by the submitted documentation and therefore, the requested service is deemed 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 adjustments have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional acupuncture office visits/adjustments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on August 2, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says any and all codes on this claim are denied, and in addition, previous payments to these providers for this member are subject to recoupment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must reportservices with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour."We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code would be included in the payment for the facility. 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 foroxygenator assembly and operation services (CPT 99190) provided to the enrollee on August 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 24, 2019 by out of network provider.You asked the Plan to pay for the MRI of the lumbar spine (72148). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and available and prior authorization for certain services is also required.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 the medical services provided on June 24, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan hasto pay forthe PET/CT scan (skull to mid-thigh) with associated radiopharmaceutical provided on July 26, 2019.You asked the Planto pay forthe PET/CT scan with the radiopharmaceutical. You say that you received approval to perform a PET scan and it should be covered.The Plandenied your request. The Plansaysthatno payment can be made for the radiopharmaceutical because it was not billed with an imaging procedure.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. The Plan has provided no cogent denial rationale for this case. The case narrative submitted only mentions the radiopharmaceutical code and says that it was not billed with an imaging procedure. This is directly contradicted by the claim in the file. Code A9552 was billed with code 78815. The remittance advice indicates that 78815 was denied but does not include the definition of the reason code. The appeal letter indicates that this was denied due to no authorization; however, the provider submitted a copy of the authorization. While the code authorized was for a whole-body PET scan, and the provider only performed the scan from skull to mid-thigh, a PET scan was approved from this provider, and a PET scan was performed by this provider. There is no evidence the scan is not medically necessary whenperformed on less than the whole body nor does the Plan make this argument. We find that the denial of payment for these services is not substantiated.Therefore, we decided that the Planhas to pay forthe PET/CT scan (skull to mid-thigh) with associated radiopharmaceutical provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe nursing facility visit provided on July 31, 2018.You asked the Planto pay forthe nursing facility visit. You say that this should be paid based on medical necessity.The Plandenied your request. The Plansaysthe claim for this service was not received until after the one year filing period.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the nursing facility visit was not filed until August 26, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plandoes not haveto pay forthe nursing facility visit provided on July 31, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does nothave to pay for the MRI of the brain stem (70551) rendered on July 22, 2019 by out of network provider,"the provider". You asked the Plan to pay for the MRI. You say that you are a participating provider with the Plan and this claim has been denied incorrectly. The Plan denied your request. The Plan says they require utilization of network providers when possible and available, and require authorization for certain 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 the MRI of the brain stem (70551) rendered on July 22, 2019 by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on June 28, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan saysthatthe Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does nothave to pay for a hospital outpatient clinic visit provided on June 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 12, 2019.You asked the Plan to pay for the physician's services. You say that you were not aware that the physician is no longer participating with the Plan. 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 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. ThePlan did notpre-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 providedon September 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 6, 2019 by out of network provider, "the hospital". You asked the Plan to pay foran ultrasound. 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 referring provider, Sheena Colclough, C.N.P., is an out-of-network provider. The Plan says that the primary care physician did not refer the enrollee 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 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 forthe medical services provided on May 6, 2019 by out of network provider, "the hospital".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for the 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTresiba Flextouch injectors.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveTresiba Flextouch injectors.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.