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

We decided that the Planhasto pre-approveacupuncture.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. 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 acupuncture is medically reasonable and necessary. Our physician reviewer found the health plan's acupuncture policy is out of date, as the new Decision Memo for acupuncture for chronic low back pain was released on 1/21/20. The enrollee meets the criteria of the memo, as there is evidence of chronic low back pain, due to spinal stenosis and post-laminectomy syndrome.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Planhas to pre-approveacupuncture.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a caseagain if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveweight-loss surgery to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON weight-loss surgery. You say that you need this surgery and in-network providers will not provide it.The Plan denied your request.The Plan says the requested surgery is available from in-network providers.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 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-approveweight-loss surgery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical nutrition therapy.You asked the Plan to pre-approvemedical nutrition therapy services. You say that it is maintaining your health.The Plan denied your request. The Plan says the service is only covered for those who have diabetes, renal disease, and after a transplant.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pre-approvemedical nutrition therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea genetic swab pancreatic test.You asked the Planto pre-approvethe test. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information shows that this is a health screening test.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 test. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee currently has cancer, or is believed to have cancer. There is no evidence that decisions regarding the treatment of cancer need to be made. The requested testing appears to be for screening purposes based on a family history of pancreatic cancer. Therefore, there is no evidence to support that the requested test is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition.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 test have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea genetic swab pancreatic test.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the abdomen and pelvis for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere has been no examination of the colon.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 tocarefully 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 medically reasonable and necessary. Our physician reviewer found abdominal ultrasound was done 2/14/20 and showed fatty liver. The enrollee has lower abdominal pain and blood per rectum. She also has been previously anticoagulated for DVT. CT of the abdomen and pelvis is the next reasonable test and should be approved.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 Planhas to pre-approveCT scan of the abdomen and pelvis for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvea specialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea specialist office visit. You say that you would like approval to see this specific physician.The Plan denied your request. The Plan says there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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-approvea specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 the requested physician's services.
Appeal type: Practitioner Services
Decision: Favorable

We decided the Plan must pay forinpatient care provided from September 20, 2019 to September 21, 2019. You asked the Plan to pay forinpatient care. You say that you were experiencing severepain. You state that youa friend drive you to an emergency room. You stated the hospital representative told you they were working on contacting your health Plan. You stated that due to the pain and the treatment received you were not able to contact the Plan yourself.The Plan denied your request. The Plan says that you did not have prior authorization for out of network care.Medicare says that plans must pay for emergency and urgently needed services. The plan contract says that a "medical emergency" is when you have severe pain, or a medical condition that is quickly getting worse. The contract says that you should go to the nearest emergency room. The Plan contract says you do not need to get approval or a referral first from your PCP. The Plan contract says that you or someone else should call to tell the Plan about your emergency care, usually within 48 hours. Based on the medical records providedand your written appeal, you were experiencing severe worsening pain. You had a friend drive you to the nearest emergency room. You were told by the hospital staff that they would contact your health plan. You followed all the rules expressed in your Plan contract on how you should handle a medical emergency. Therefore, we decided that the Plan mustpay forinpatient care provided from September 20, 2019 to September 21, 2019. 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 toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe continuous positive airway pressure ventilation (CPAP) initiation and management services coded 94660 providedon June 12, 2019.You asked the Plan to pay forthe CPAP initiation and management services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by thedocumentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 94660 is Continuous positive airway pressure ventilation (CPAP), initiation and management.We find that CPT code 94660 is not supported in the medical record. Specifically, the documentation does not support that these services were performed on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the CPAP initiation and management services have not been met. Therefore, we decided that the Plan does not have to pay forthe continuous positive airway pressure ventilation (CPAP) initiation and management services coded 94660 provided on June 12, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78811).You asked the Plan to pre-approvethe PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says that the PET scan is not indicated.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 pre-approve the PET scan. Our reviewer says that rules for coverage have been met. Our physician reviewer found a 4D CT scan, considered a second line confirmatory test, had indeterminate results. The PET scan can potentially help clarify lesions noted on the CT scan and can better direct surgical cure.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 PET scan have been met.Therefore, we decided that the Plan has to pre-approvea Positron Emission Tomography (PET) scan (78811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have foot pain and your podiatrist recommends orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (CPT Code A0888) provided on October 21, 2019.
You asked the Plan to pay for the services. You say that you have no control as to the mileage used by an ambulance to take you to the hospital. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This ambulance code represents a service which is specifically excluded from coverage by Medicare. The denial is always member responsibility because the Plan does not contract with ambulance providers. Therefore, we decided that the Plan does not have to pay for noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (CPT Code A0888) provided on October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram (77067) 
You asked the Plan to pay for the mammogram. You say that the services were medically necessary. The Plan denied your request. The Plan says a corrected claim is required.
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 77067 is not supported in the record. Specifically, the documentation shows the claim form was submitted with the incorrect Tax ID number (TIN). Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a mammogram (77067)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe arthrocentesis provided on November 20, 2019.You asked the Plan to reduce the copayment forthe arthrocentesis. You say that you should not be charged for a treatment room. You say you should only pay $25.00 for a specialist. 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 $275 copayment for Medicare-covered outpatient hospital and observation services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for the outpatient service.You have been asked to pay a $221.41 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient hospital 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 reduce the copayment forthe arthrocentesis provided on November 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment. The enrollee's functional level does not
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to
safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or
skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a
practical matter this enrollee does not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader.
You asked the Plan to pre-approve a Freestyle Libre 14 day reader. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 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 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 Freestyle Libre 14-day reader. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to have diabetes. You do not use insulin. There is no evidence that you check your blood glucose multiple times a day and use those results to self-adjust self-administered insulin. Therefore, the use of a continuous glucose monitor (CGM) is not shown to be 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 a Freestyle Libre 14 day reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 26, 2019.You asked the Plan to pay for the drug test. You say that you did not know authorization was required for this service. The Plan denied your request. The Plan says there is no authorization for this service.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 and the referring provider in this case are not network providers with the Plan. The Plan did not pre-approve the drug test.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 a drug test provided on November 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance forthe esophagogastroduodenoscopy and the anesthesia services received on October 23, 2019.You asked the Plan to waive the deductible and coinsurance forthe esophagogastroduodenoscopy and the anesthesia services. You say that you disagree with the amounts owed.The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $700 deductible that you must pay out-of-pocket before the plan will pay their share for your covered medical services. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category that you must pay out-of-pocket before the plan will pay their share for your covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $700 deductible that you must pay out-of-pocket before the plan will pay their share for your covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 25% coinsurance for each visit to an outpatient hospital facility or ambulatory surgical center for outpatient surgery.This cost sharing is a contractual obligation that had not been met at the time the esophagogastroduodenoscopy and the anesthesia services were received on October 23, 2019.Therefore, we decided that the Plan does not have to waive the deductible and coinsurance forthe esophagogastroduodenoscopy and the anesthesia services received on October 23, 2019.