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

We decided that the Plan does not have to pre-approve a Vertiflex device.You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. 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 a Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2021 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 had network providers available who could have provided 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 laboratory services provided on January 6, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the bls-emergency transport (A0429, A0425) services provided on October 21, 2020.
You asked the Plan to pay for the bls-emergency transport (A0429, A0425) services. The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that bls-emergency transport (A0429, A0425) services are not necessary. Our physician reviewer found that the medical records do not support the use of ambulance services as the medical state of this enrollee was not emergent per records. There is no indication of fever with an increased temperature and her vitals were normal and she was hemodynamically stable.
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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for bls-emergency transport (A0429, A0425) services provided on October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L4-L5 minuteman interspinous-interlaminar fusion surgery.
You asked the Plan to pre-approve L4-L5 minuteman interspinous-interlaminar fusion surgery. You say that the requested L4-L5 minuteman interspinous-interlaminar fusion surgery is medically necessary. The Plan denied your request. The Plan says the requested L4-L5 minuteman interspinous-interlaminar fusion surgery is 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 L4-L5 minuteman interspinous-interlaminar fusion surgery. Our reviewer says that the requested L4-L5 minuteman interspinous-interlaminar fusion surgery is not medically necessary. Our physician reviewer found the enrollee is with chronic intractable pain due to lumbar spinal stenosis with grade 1 spondylolisthesis. Interspinous-interlaminar fusion surgery and the devices used for it remain experimental for use. More research is needed to show safety and efficacy of the procedure and the devices.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of L4-L5 minuteman interspinous-interlaminar fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve L4-L5 minuteman interspinous-interlaminar fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (9336) provided on November 3, 2020, by
an OON provider.
You asked the Plan to pay for the rest home visit. You say that you would like reconsideration because this
physician relies on hospital staff to verify eligibility and obtain authorization. The Plan denied your request.
The Plan says these services were not urgent, emergent or approved in advance.
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 had network providers
available who could have provided 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 rest home visit (9336) provided on November
3, 2020, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from December 1, 2020, through December 5, 2020.

You asked the Plan to pay for the SNF services. You say that these services were billed correctly The Plan denied your request. The Plan says the code submitted is inconsistent with what was approved by the provider on the authorization.

The Plan contract says skilled nursing facility services require prior authorization.

We looked at the file and the Plan's rules. The file shows that the claim was not billed with the correct code that was authorization by the Plan. Therefore, we decided that the Plan does not have to pay for SNF services provided from December 1, 2020, through December 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (E0766).

You asked the Plan to pre-approve tumor treatment field therapy. You say that this request is medically necessary. The Plan denied your request. The Plan says this service is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of recurrent glioblastoma. 

We looked at the file and Medicare rules. In this case, the enrollee has been diagnosed with recurrent glioblastoma. Based on this information, we decided that Medicare rules for coverage of tumor treatment field therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (E0766).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional outpatient physical therapy sessions for
the enrollee.
You asked the Plan to pre-approve the additional sessions. You say that this is medically necessary. The Plan
denied your request. The Plan says twenty additional outpatient physical therapy sessions have already been
approved.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional sessions. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as
specific and effective therapy for the enrollee's condition, beyond what was approved by the health plan. The
enrollee has had prior therapy of twenty outpatient visits and the records do not demonstrate that the unique
skills of a professional therapist are required to safely and effectively provide treatment, that the services can
be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee
has been instructed in a home exercise program.
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 additional sessions have not been met. Therefore, we decided that the Plan
does not have to pre-approve ten additional outpatient physical therapy sessions for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on January 1, 2021, to January 25, 2021.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you had to stay longer due to testing positive to Covid-19. You say that this required you to be isolated. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $0
copayment per day for days 1-20. There is a $178 copayment per day for additional days for skilled nursing facility (SNF) care. You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-26 for a skilled nursing stay. The total amount you are being asked to pay is $1,068 ($178 x 6 days = $1,068). This is a continuation from a stay that started on December 30, 2020. A skilled nursing stay falls within the skilled nursing facility (SNF) 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 a skilled nursing stay provided by a participating provider on January 1, 2021, to January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Movantik.
You asked the Plan to pre-approve Movantik. You say that you would like this drug to be approved for
coverage for the enrollee. The Plan denied your request. The Plan says the requested drug is intended for selfadministration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Movantik.
Benefits for Movantik may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with acute hypercapnic respiratory failure and chronic obstructive pulmonary disease. She continues to receive acute critical care services and they have not been denied. The record does not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH facility. The elements of the coverage criteria are not satisfied. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the physical therapy (PT) services provided on January 28, 2021, and February 5, 2021.
You asked the Plan to waive the charges for the PT services. You say that you do not know why you were charged $40 for these visits. The Plan denied your request. The Plan says you were correctly assessed up to the $40 copayment for each of the PT visits on these two dates.
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 physical therapy visits.
You have been asked to pay a $40 copayment for each of the two PT visits. The PT services fall within the physical therapy visits 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 charges for the physical therapy (PT) services provided on January 28, 2021, and February 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for office services provided from November 9, 2020, to November 18, 2020.
You asked the Plan to pay for office services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 did not provide a copy of the applicable Evidence of Coverage for 2020. Without this, we cannot determine whether the enrollee's contract with the Plan includes any network lock-in or prior authorization rules that may apply to this case. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified according to Medicare rules or the enrollee's contract with the Plan. Therefore, we decided that the Plan has to pay for office services provided from November 9, 2020, to November 18, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for recent stroke and left hemiparesis. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin seal protect moisturizer (A6250).
You asked the Plan to pre-approve skin seal protect moisturizer. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that certain wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin seal protect moisturizer have not been met. Therefore, we decided that the Plan does not have to pre-approve skin seal protect moisturizer (A6250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99213) provided on December 10, 2020.
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service.
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. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99213) provided on December 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. You say that you would like to improve on going up the stairs and going out and you feel that additional physical therapy will make you more independent. The Plan denied your request. The Plan says you have not made significant improvements.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 an additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You should be able to transition to an independent home exercise program at this point. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99203) provided on September 12, 2018.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 had network providers available who could have provided 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 for physician services (99203) provided on September 12, 2018.