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

We decided that the Plan does not have to pay for Foundation One testing provide on March 9, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with all information to validate the medical necessity for testing. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the enrollee received the same testing for the same genetic content in April 2018.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing testing may be covered if the enrollee has not been previously tested with the same test using NGS for the same cancer genetic content. We looked at the file and Medicare rules. The enrollee was previously tested with the same test for the same genetic content in April 2018. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Foundation One testing provide on March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the clinical documentation provided supports the need for respiratory/ventilator skilled nursing. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the respiratory and physical therapy that the enrollee requires can safely be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition, had stable vital signs, and remained ventilator dependent. The enrollee had wound care to his sacrum. The enrollee received physical therapy and occupational therapy in the acute hospital. the enrollee was at a maximal assist level with bed mobility. The enrollee required maximal to total assist with activities of daily living. There are no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the enrollee's member card did not state that a referral was required. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 office visit provided on May 18, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve genetic testing. You say that you were advised by your physician to get genetic testing done. The Plan denied your request. The Plan says there is no documentation of any signs or symptoms of cancer.
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. The records show that you do not have a personal history of breast, ovarian, or pancreatic cancer. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the aorta you had on February 15, 2021.
You asked the Plan to waive the copayment for the duplex scan of the aorta. You say that your doctor made this appointment for you and you did not have a choice of provider. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for radiological diagnostic services in a physician's office or free-standing facility. You have been asked to pay a $160 copayment for the duplex scan of the aorta. The duplex scan of the aorta falls within the radiological diagnostic services in a physician's office or free-standing facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the duplex scan of the aorta you had on February 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided to the enrollee on November 22, 2020.
You asked the Plan to waive the copayment for the services. You say that you were told that you would not need to pay anything due to your coronavirus diagnosis. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment for ambulance services. You have been asked to pay a $260 copayment for the services. The services fall within the ambulance services 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 ambulance services provided to the enrollee on November 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) received on November 3, 2020.

You asked the Plan to waive the copayment for the MRI. You say that the service was preventive, and the copayment should be waived. The Plan denied your request. The Plan says the plan does not cover your cost-sharing responsibility.

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 $195 copayment for other outpatient diagnostic tests. 

You have been asked to pay a $195 copayment for the MRI. the MRI falls within the other outpatient diagnostic tests 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 magnetic resonance imaging (MRI) received on November 3, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenetic testing provided on February 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that you continue to do your part in providing 
timely testing and results. The Plan denied your request. The Plan says that Medicare denies coverage for all 
cardiovascular risk assessment testing for suspected or documented cardiovascular disease. 
 
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. 
 
In this case, the Plan used Local Coverage Determinations and Articles regarding cardiovascular risk 
assessment testing. The Plan did not provide Medicare rules or a decision regarding the pharmacogenetic 
testing that was provided. Furthermore, the Local Coverage Determinations and Article (L36139, L36362, 
L36523, A57055, and A57559) the Plan used in their decision is not binding in this case. The rules do not have 
Medicare Part B jurisdiction where the services were provided. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we 
decided that the Plan has to pay for the pharmacogenetic testing provided on February 12, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance E0673) provided September 16, 2020.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that this equipment was prescribed by the surgeon and deemed medically necessary due to the type of surgery performed combined with other risk factors as determined by the physician. The Plan denied your request. The Plan says this is a Medicare non-covered benefit.
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 enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance E0673) provided September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care and wound care provided on December 4, 2020 by an out-of-network provider.
You asked the Plan to pay for nursing facility care (99309) and wound care (11042). You say that the services were medically necessary to avoid delay in care. The Plan denied your request. The Plan says you did not obtain prior authorization as required.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for nursing facility care and wound care provided on December 4, 2020 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 9, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it was not the enrollee's decision to not be transported. You also say that you feel the service should be covered because this bill will be a financial hardship for the enrollee. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 9, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The records show that the enrollee advised they did not want to go to the hospital, and a refusal was signed. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of a home health/hospice aide in home health
or hospice settings (G0156).
You asked the Plan to pre-approve the services of a home health/hospice aide in home health or hospice
settings. You say that you would like to appeal these services for help with meals, transportation, shopping,
cleaning, bathing, and grooming. The Plan denied your request. The Plan says you are not receiving skilled
nursing care on an intermittent basis or physical therapy, speech language pathology, or have a continuing need
for occupational therapy.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 services of an HHA in home health
or hospice settings. Our reviewer says that the services of an HHA in home health or hospice settings (G0156)
are not medically reasonable and necessary. Our physician reviewer found after July 15, 2021, you were no
longer receiving home health registered nurse or home health physical therapy and, therefore, are no longer
eligible for associated HHA 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 the services of a home health/hospice aide in home health or hospice settings
have not been met. Therefore, we decided that the Plan does not have to pre-approve services of a home
health/hospice aide in home health or hospice settings (G0156).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you received on March 19, 2021.
You asked the Plan to waive the copayment for the ECG. You say that you have had many appointments with a cardiologist and electrophysiologist since being hospitalized in March. You stated that you think you should not have to pay a separate copayment for ECGs because you already have to pay copayments to see these providers. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan also says that because the allowed amount for the ECG ($11.42) is less than your copayment obligation, you are responsible for the full allowed 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 $20 copayment for non-radiological diagnostic services. You have been asked to pay a $20 copayment for the ECG. The ECG falls within the non-radiological diagnostic services benefit category. This copayment applies even if you have a specialist visit on the same day. 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 electrocardiogram (ECG) you received on March 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that you are having trouble with mobility and balance. You say that you are not able to care for yourself and are a fall risk which could lead to readmission to the hospital. The Plan denied your request. The Plan says the request is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require skilled nursing or therapy services on a daily basis. Our reviewer says that you do not the 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 you are receiving appropriate care at the present acute care hospital and you do not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being obtained at your current level of care and you do not require any additional services.

This means admission into an LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve sleep study. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan has not received information from your treating doctor as to why this test needs to be done.
The Plan follows Medicare rules. Medicare rules state that sleep studies may be covered for evaluation of obstructive sleep apnea under certain clinical conditions. 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 sleep study. Our reviewer says that you do not meet the Medicare criteria for a sleep study. Our physician reviewer found you were referred for a sleep study for suspected obstructive sleep apnea, but the medical records are mostly silent on what - if any - symptoms of obstructive sleep apnea you have. Therefore, this request would not be 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 1, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you did not request this transport and you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment for each ambulance trip. You have been asked to pay a $260 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).
You asked the Plan to pre-approve Osteogenesis stimulator. You say that your doctor said that because you have osteoporosis and this is your second fracture, the bone stimulator will aid in faster healing. The doctor would not have deemed necessary if she thought it would not help. The Plan denied your request. The Plan says the service is not reasonable and necessary as the Medicare 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 looked at the file and Medicare rules. A minimum of 2 sets of radiographs, separated by a minimum of 90 days, obtained prior to starting treatment with the osteogenic stimulator is required. The records show only one set of x-rays were completed on May 11, 2021, and the enrollee starting using the device on the same day and is still using it. Based on this information, we decided that Medicare rules for coverage of Osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve Osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).