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

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 26, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that you have no one to assist you upon discharge.The Plan denied your request. The Plan says continued therapy services can be provided on an intermittent basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you are at moderate independence for mobility, and your vital signs are stable. You do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Your functional level does not require skilled therapyservices with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require these skilled nursing or skilled therapy services (ora combination of these services) on a daily basis. As a practical matter this patient does not require the necessary services on an inpatient basis, in a SNF setting.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781), photochromatic tint (V2744), frames (V2020), and lens coating (V2750) provided on August 29, 2019 and September 26, 2019.
You asked the Plan to pay for progressive lenses, photochromatic tint, frames, and lens coating. You say that this should be covered because you had cataract surgery in 2017. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL. Otherwise, Medicare does not pay for low vision aids.
The record does not indicate either set of eyewear at issue is the first pair of conventional eyeglasses furnished after a cataract surgery. Furthermore, covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades, such as progressive lenses and lens coatings, are not covered. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), photochromatic tint (V2744), frames (V2020), and lens coating (V2750) provided on August 29, 2019 and September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEliquis 5mg tablets.You asked the Planto pre-approvethe Eliquis tablets. You say that the enrollee needs this medication to prevent stroke due to new onset atrial fibrillation.The Plandenied your request. The Plansaysthe requested drug cannot be covered by Medicare Part B.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 Plandoes not haveto pre-approveEliquis 5mg tablets.Benefits forthe Eliquis tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you went to the provider with medical complaints. The Plan denied your request. The Plan says no prior authorization was obtained 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 for an office visit provided on August 8, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Romosuzumab (Evenity) injections.
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not tried and failed, or had an intolerance to at least two alternatives such as one of alendronate, Risedronate, or Ibandronate; and Prolia or Forteo.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Evenity. Our physician reviewer found that you have age-related osteoporosis without current pathological fracture. The Plan requires a trial of one of alendronate, Risedronate, or Ibandronate; and Prolia or Forteo before they will approve the requested drug. The documentation does not show that you have tried and failed the required drugs. It is not clear that the required drugs would likely be less effective, or would likely have adverse effects for the enrollee in this case. Multiple drugs are available for treating the enrollee's condition, and an optimal management plan in this setting has not been clearly determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Romosuzumab (Evenity) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 2, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be charged for a follow up visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for in-network specialist visits. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 2, 2019.
Our decision is only about the October 2, 2019 appeal request. If you have any questions about other appeals, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on November 6, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99152 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers mustreport 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 by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trainsed observer to assist in monitoring the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services rendered on November 6, 2019.
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 the enrollee is physically still in bed in
CVU. The Plan denied your request. The Plan says at this time, the enrollee does not
require close doctor supervision daily, and his needs can be provided for at a lower level of care.
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 is currently undergoing treatment at an ACH following cardiac surgery.
The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level
of care for any ongoing long term care needs.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care related to a transcatheter aortic valve replacement (TAVR) provided from August 1, 2019 to August 5, 2019.
You asked the Plan to pay for the inpatient TAVR admission. You say that this enrollee is not part of a clinical trial so there should be no requirement to report a clinical trial number. The Plan denied your request. The Plan says Medicare only covers this procedure when provided to a patient enrolled in a CMS-approved registry. The trial number of the registry must be reported on the claim.
The Plan must follow Medicare rules. Medicare rules say that TAVR services are covered under CED. This means that it is covered only when provided to patients enrolled in an approved clinical registry. The claim was not submitted with the trial number of the clinical registry in which the enrollee participated. There is no evidence that the enrollee was participating in a clinical registry. As such, the Medicare rules for coverage of TAVR have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care related to a transcatheter aortic valve replacement (TAVR) provided from August 1, 2019 to August 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you cannot use your right arm. The Plan denied your request. The Plan says you are not progressing in your mobility and self-care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. Continued services beyond February 21, 2020 were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are ambulating with contact guard assist. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 2, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were unaware that the provider was out-of-network.
You say that you get your pacemaker checked every 6 months. The Plan denied your request. The
Plan says no prior authorization was obtained 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 for an office visit provided on December 2, 2019 by
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection without guidance for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the use of fluoroscopy is supported for needle guidance, and the records do not show this type of guidance is planned for the injection.
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 standard of care for performing an epidural steroid injection is with image guidance. There have been numerous serious neurologic injuries reported in the literature from simple unguided caudals. Therefore, the requested procedure is 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection without guidance for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine foot care rendered to the enrollee on February 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of the conditions for which Medicare covers routine foot care are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe routine foot care rendered to the enrollee on February 21, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 18, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on August 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab tests. 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 for these services. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient lab tests provided on August 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 26, 2019.
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 procedure code 99204 is not supported.
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 99204 is new patient office or other outpatient visit, typically 45 minutes. We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that the enrollee was seen by the provider at issue on July 5, 2019; July 11, 2019; and July 16, 2019; therefore, a "new patient office visit" was not appropriate for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 11720 provided on March 8, 2019.
You asked the Plan to pay for CPT code 11720. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that a covered secondary diagnosis code is to be reported with B35.1 or L60.2-L60.3 for treatment of mycotic nails, onychogryphosis, and onychauxis to indicate medical necessity. We looked at the file and Medicare rules. The claim was not billed with a covered secondary diagnosis code. Based on this information, we decided that Medicare rules for coverage of CPT code 11720 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 11720 provided on March 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 1, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 1, 2019.