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

We decided that the Plan does not have to pay for the outpatient hospital services rendered from February 1, 2021 to February 25, 2021.
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 not billed correctly.
The Plan must follow Medicare rules. The rules say that for claims submitted with dates of service on or after January 1, 2012, all drugs reported on the ESRD claim under revenue codes 0634, 0635 and 0636 with a rate available on the ASP file will be considered in the Medicare allowed payment (MAP) amount for outlier consideration with the exception of any drugs reported with the AY modifier. We looked at the file and Medicare rules. The drug services were not billed with the required AY modifier. 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 outpatient hospital services rendered from February 1, 2021 to February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multilevel spinal stenosis without quantification. and the imaging report is not available to review. The record does not indicate that operative therapy is not indicated at no more than two levels. 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram provided on May 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for electrocardiogram. You say that you were told that this provider was in-network. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 an electrocardiogram provided on May 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-area office visits (99203, 99214) provided on March 25, 2021, to April 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for out of area office visits. You say that you spend four months in Arizona each year due to your congestive heart failure and the inability to tolerate the coldest months in New York. The Plan denied your request. The Plan says you exhausted your POS benefit.
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 records show you exhausted your out-of-network benefit on March 15, 2021. Please note, that the Plan will reimburse a maximum of $3,000 for out-of-network POS services per calendar year. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 out-of-area office visits (99203, 99214) provided on March 25, 2021, to April 19, 2021, by an out-of-network (OON) provider.
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 enrollee needs IRF care. The Plan denied your request. The Plan says the enrollee can safely receive services needed in other settings.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 20, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The record shows that this testing was ordered by a podiatrist that was out-of-network with the Plan. The record does not show that the results of this testing were requested for the management of the enrollee's specific medical problem. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for tomographic myocardial perfusion imaging provided on November 4, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the SPECT. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the member's health plan and listed in the Provider Directory.

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 tomographic myocardial perfusion imaging provided on November 4, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's rehabilitation cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee does not need an intensive team to oversee care.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical management of a hip fracture and non-surgical management of a wrist fracture. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, extraction and consultation provided on March 24, 2021.
You asked the Plan to pay for the panoramic x-ray, extraction and consultation. You say that the previous dental work caused a massive infection and the tooth was extracted. You say that you should be reimbursed the $138 you had to pay. The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the claim processed correctly per your dental benefits. Your contract has a maximum benefit of one complete series or panoramic x-ray every five years. The Plan paid for complete series x-rays provided on October 25, 2018, which exhausted your benefit. The Plan also paid 50% of the cost for the extraction and the consultation is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, extraction and consultation provided on March 24, 2021.
Your complaint about the negligence is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient was admitted for sepsis, urinary tract infection and acute kidney injury. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.

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 the drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Supartz FX is not approved, as step criteria have not been met. There is also no documentation that the plan's required drugs are likely to be less effective and/or likely to have adverse effects for the enrollee. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for your medical claims for services provided out of area from January 20, 2021, to January 28, 2021.
You asked the Plan to reimburse you for your medical claims for services provided out of area. You say that the claims are legible, and you should be reimbursed. The Plan denied your request. The Plan says they are unable to process the receipts because they are illegible.
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. Most of the wording on the receipts and claims is in a foreign language making them illegible.
Based on this information, we decided that Medicare rules for coverage of your medical claims for services provided out of area have not been met. Therefore, we decided that the Plan does not have to reimburse you for your medical claims for services provided out of area from January 20, 2021, to January 28, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 retainer crowns (D6750), and 16 pontics (D6245).
You asked the Plan to pre-approve the dental services. You say that your dentures are in poor condition. You say that you cannot chew food. You also say that this is causing you to have stomach problems. The Plan denied your request. The Plan says bridges are not covered if you are missing back teeth.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the requested retainer crowns and pontics are not medically necessary. Our physician reviewer found multiple posterior teeth are indicated to be replaced. The reviewer found that this request is beyond the scope of the plan for fixed bridgework. Therefore, the reviewer found that the requested services are not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 retainer crowns (D6750), and 16 pontics (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry visit, and the debridement provided on May 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the podiatry visit and the debridement. You say that you did not realize the provider was out-of-network and you needed authorization. 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 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 podiatry visit, and the debridement provided on May 13, 2021 by an out-of-network (OON) provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for hyponatremia and possible seizure after recent intracranial hemorrhage. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says the family cancer history does not meet criteria for testing.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this should be denied, as you and your moth had breast cancer in your 70s. This does not meet the LCD requirements. You would need another close relative to meet the LCD testing requirements. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA testing.