Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).You asked the Plan to pre-approvethe requested device. You say that you have diabetes, and you pass out after eating.The Plan denied your request. The Plan says there is no benefit for a person who is not on multiple doses of insulin a day, or using an insulin pump.The Plan follows Medicare rules. Medicare rules say that glucose monitors are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested device. Our physician reviewer found that the documentation does not show you are diabetic, that you use insulin, that you test your blood glucose multiple times a day, or that you use the results of blood glucose monitoring to adjust insulin dosages. Therefore, the documentation does not support that the requested CGM is medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the recliner bed provided on February 3, 2019.You asked the Plan to pay forthe recliner bed. You say that you should be reimbursed for this item.The Plan denied your request. The Plan says that they cannot pay a provider who is not eligible to participate in Medicare.The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program.The purchase was not made with a supplier who is enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay forthe recliner bed provided on February 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care beyond January 17, 2020.You asked the Planto pre-approvethe continued SNF care. You say that the enrollee still requires additional therapy before she can be sent home. She also still has staples in which have to be taken out.The Plandenied your request. The Plansaysthere is no longer any need for daily skilled care. Her needs are mostly custodial.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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 66 year old female was admitted to the hospital on 12/24 for a right femur fracture. She underwent a ORIF for repair. She was discharged to the SNF on 12/30/19. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at a supervision to stand by assist level with bed mobility and transfers. She remained toe touch weight bearing to her RLE. She required varying assist with ADLs from set up to minimal assist.There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does 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 the continued SNF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care beyond January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 1, 2019 by out of network provider.You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the claim submission is missing required information.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.Review of the file shows that an itemized bill is required for reimbursement for services. The documentation does not include an itemized bill. This information is required for the claim to be valid. 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 June 1, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 9, 2019 by out of network provider. You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules say that plans can require enrolleesto 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 isnot 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 forthese items/services.Therefore, we decided that the Plan does not have to pay forthe office visit provided on July 9, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional out-of-area office visits with the physician.You asked the Plan to pre-approvethe out-of-area services. You say that you want to see your PCP to coordinate your care with your oncologist.The Plan denied your request. The Plan says the service requested is available in-network.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at the file, and Medicare rules. The requested provider is not a contract provider with the plan. Your plan has network providers available to provide the service at issue in this case. The services requested arenot urgent or emergent. Based on this information, we decided that Medicare rules for coverage of the out-of-area services have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional out-of-area office visits with the physician.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 10, 2019 by out of network provider, "the provider".You asked the Plan to pay forthese 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 referring provider 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 April 10, 2019 by out of network provider, "the provider".
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on May 29, 2019.
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not authorized.
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 for the services provided to the enrollee by an out-of-network provider on May 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the myocardial strain imaging rendered on May 3, 2019.You asked the Planto pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0399T is non-covered.The services at issue are myocardial strain imaging billed with code 0399T. This code was not covered by Medicare for the date of service at issue.Therefore, we decided that the Plan does not have to pay forthe myocardial strain imaging rendered on May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve the ActiveCare Plus intermittent pneumatic compression device (PCD) coded E0676 to be provided post-surgery.You asked the Planto pre-approvethe intermittent PCD. You say that the enrollee is not able to use anticoagulants due to bleeding risk but needs prevention of deep vein blood clots. This PCD is necessary to achieve this and should be covered.The Plandenied your request. The Plansaysthis device is not covered by Medicare as it does not treat a medical condition and is used for prevention.The Plan must follow Medicare rules. Medicare rules say that PCDs coded E0676 do not meet the definition of durable medical equipment and cannot be covered. Although this device may be appropriate, there is no coverage available for this under the DME benefit.Therefore, we decided that the Plandoes not haveto pre-approvethe ActiveCare Plus intermittent pneumatic compression device (PCD) coded E0676 to be provided post-surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for high risk prostate cancer.
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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found based upon NCCN guidelines, corroborated by expert opinion, SBRT for high risks prostate cancer would not be furnished in accordance with accepted standards of medical practice. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on February 7, 2019 byout of network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network provider withoutprior 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 referring provider 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 laboratory services provided on February 7, 2019 by out of network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveTrulicity 1.5mg/0.5mL pens.You asked the Planto pre-approvethe Trulicity pens. You say that this medication is necessary for the enrollee's condition.The Plandenied your request. The Plansaysthis is a self-injected drug and is not 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-approveTrulicity 1.5mg/0.5mL pens.Benefits for the Trulicity pensmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency department services provided on August 5, 2019.You asked the Plan to pay forthe emergency department services. You say that the claim has not been paid in full or under the terms of the contract for services provided to the patient.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare-covered services related or unrelated to the member's terminal illness.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.The record shows proof of hospice election from June 27, 2019 to August 5, 2019. Therefore, we decided that the Plan does not have to pay foremergency department services providedon August 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary at this time.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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare will probably not pay for the SNF services after the effective date.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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 office visits (99214), 9 EKGs (93000), an
echocardiography (an echo) (93306), a duplex scan (93880), a permanent dual lead pacemaker system (93280),
and a cardiovascular stress test (93015) to be provided by the out of network provider.
You asked the Plan to pre-approve 10 office visits, 10 EKGs, an echo, a duplex scan, an influenza vaccine and
its administration, a permanent dual lead pacemaker system, and a cardiovascular stress test. You say that you
are not contracted with the member's plan at this moment however you are working the Plan relations now.
The Plan denied your request. The Plan says the physician is an out-of-network provider and not a
member of the health plan. The Plan also says they have agreed to pre-approve a portion of services with the physician for a transition of care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve 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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
9 office visits (99214), 9 electrocardiograms (EKGs) (93000), an echocardiography (an echo) (93306), a duplex
scan (93880), a permanent dual lead pacemaker system (93280), and a cardiovascular stress test (93015) to be
provided by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on September 7,2019.You asked the Plan to pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get carefrom 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 by an out-of-network provider on September 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from September 17, 2019 to September 20, 2019.You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you cannot afford the copayment for the hospital stay. 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 $300 copayment per day for days 1-5 for Medicare-covered in-network inpatient hospital stays. You have been asked to pay a $300 copayment for each day of the inpatient hospital stay. ($300 x 3 days = $900). The inpatient hospital stay falls within the "Inpatient hospital 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 reduce the copayment forthe inpatient hospital stay provided from September 17, 2019 to September 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says there was no diagnostic imaging before this request.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the provided information does not include notes from a recent office visit or a report from a chest x-ray within the past 90 days. Likewise, there is no description of whether the cough is productive. There is not enough clinical information to provide a valid indication for a chest CT. There is a mention of a secondary tumor within the brain but the primary tumor is not described.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee.