Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided on December 14, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not emergent or pre-authorized. There were network
providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided
that the Plan does not have to pay for lab services (80307) provided on December 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluations (90791) individual psychotherapy 30 minutes (90832) provided April 5, 2021 to April 22, 2021.
You asked the Plan to pay for the outpatient services. You say that your doctor referred you for mental health counseling and the referral was approved. The Plan denied your request. The Plan says mental health counselors are ineligible mental health providers and not eligible to participate with Medicare enrollee's.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychiatric diagnostic evaluations (90791) individual psychotherapy 30 minutes (90832) provided April 5, 2021 to April 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care services (99288) provided to the enrollee on February 25, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says separate payment is not allowed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99288 is not supported in the medical record. Specifically, this code is considered status B, according to the Medicare Physician Fee Schedule. This status indicator means that the code is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency care services (99288) provided to the enrollee on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.

You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion Interspinous spacer at L2-3 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 a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit received on May 19, 2021.

You asked the Plan to pay for the services. You say that this should be covered, as you wouldn't want to self-diagnose. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit received on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on December 30, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the doctor performed the medical assessment on the enrollee as requested with the assurance that the facility had all the proper authorizations in place. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 subsequent nursing facility care (99309) provided on December 30, 2020 by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for nineteen (19) additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the benefit maximum for non-emergency transportation trips is 24 one-way trips to approved locations per benefit period. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for nineteen (19) additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiovascular stress testing (93015), cardiac monitoring (A9555), an injection (J2785), perfusion imaging (78492) and an echocardiograph (93306) provided February 11, 2021 to February 26, 2021.
You asked the Plan to waive the copayment for the stress testing, cardiac monitoring, injection, perfusion imaging and echocardiograph. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B Drugs, a $20 copayment for non-radiological diagnostic services, and a $110 copayment for diagnostic radiology. You have been asked to pay a 20% coinsurance for the injections, a $20 copayment each for the stress testing, cardiac monitoring, and echocardiography, and a $110 copayment for the perfusion imaging. 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 cardiovascular stress testing (93015), cardiac monitoring (A9555), an injection (J2785), perfusion imaging (78492) and an echocardiograph (93306) provided February 11, 2021 to February 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 20, 2021.
You asked the Plan to pay for the laboratory services. 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 condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. 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. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 20, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a PET/CT from skull to mid-thigh provided to the enrollee on February 4, 2021.
You asked the Plan to pay for the scan. You say that this was medically necessary. The Plan denied your request. The Plan says that the associated diagnosis code relationship criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the scan. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found the diagnosis of malignant mesothelioma (proven on biopsy) qualifies for the PET/CT done on 2/4/21. The body of the report describes the pleural effusion/mass as right sided. 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 been met. Therefore, we decided that the Plan has to pay for a PET/CT from skull to mid-thigh provided to the enrollee on February 4, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4291) and a bone replacement graft (D7953).
You asked the Plan to pre-approve gingival irrigation and a bone replacement graft. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4291) and a bone replacement graft (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair (K0800) and a battery (E2365).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that the home does not provide enough room for use of the power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation indicates that you do not have ample space inside the home for use of the power wheelchair. Therefore, the requested wheelchair is intended for community use only. 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 Plan does not have to pre-approve a group 1 standard power wheelchair (K0800) and a battery (E2365).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is not medically necessary. You can receive the care you need in a nursing home or you may be able to go home with home health 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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable.
There are no complex nursing or rehabilitation needs. You do 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 you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the criteria is not met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. Their denial appears to be based on medical reasons, claiming that coverage is only provided where the patient has been using a blood glucose monitor, and performing frequent testing. There are no medical records provided by the plan to verify if their denial reason is valid. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre for the enrollee.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you do not feel comfortable driving to the medical center because you had a driving accident, which has caused you to be more concerned to drive. The Plan denied your request. The Plan says you have exhausted all 20 one-way trips for this year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo (nivolumab) (J9299).
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that the treatment requested by your physician above is not medically necessary for your diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo. Our reviewer says that Opdivo is medically necessary. Our physician reviewer found the requested use of Opdivo is FDA-approved for the enrollee's diagnosis when used in combination with fluoropyrimidine- and platinum-containing chemotherapy. The reviewer also found that the documentation supports that the Opdivo is safe and effective and otherwise reasonable and necessary for this 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 Opdivo have been met. Specifically, the record shows that Opdivo is FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan has to pre-approve Opdivo (nivolumab) (J9299).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services. You say that this provider specializes in treating people with osteoporosis. The Plan denied your request. The Plan says you must use network providers to get medical care and services when there are network providers available
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.
You asked the Plan to provide coverage for additional routine, non-emergency transportation trips. You say that you require additional transportation to your physician's appointments, and you do not have any other transportation. The Plan denied your request. The Plan says that the evidence shows the enrollee has used twenty-nine (29) one-way trips of the thirty-two (32) one-way trips covered by the health Plan for the year 2021. The enrollee has three (3) one-way trips available. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan benefit covers thirty-two (32) trips, one-way trip or return trip, each year. Therefore, we decided that the Plan does not have to provide coverage for additional routine, non-emergency transportation trips.