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

We decided that the Plan does not have to pre-approve a POV (K0812).
You asked the Plan to pre-approve the POV. You say that the member is limited in terms of necessary mobility needs without the scooter. The Plan denied your request. The Plan says medical necessity criteria have not been met.
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 POV. Our reviewer says that the documentation does not support that the requirements for Medicare coverage have been met based on the LCA. Our physician reviewer found the medical assistant progress note dated October 23, 2019 indicates that a referral has been made to physical therapy for a DME evaluation. The evaluation is not present in the documentation. The medical records submitted are insufficient to support that the power operated vehicle (K0812) is reasonable and medically necessary for this enrollee, as there has not been an evaluation performed by a licensed certified medical professional. 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 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0812).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 26, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you were never given the opportunity to find your own transportation.The Plan denied your request. The Plan says that they applied the copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground ambulance trip benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided on September 26, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscurrent needs can be continued at a lower level of care, in the home, with home therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee'smedical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forcataract surgery provided on August 15, 2019 and August 29, 2019.You asked the Plan to waive the copayment forcataract surgery. You say that the surgery was a success. You say that you are appealing the $620.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 copayment for surgery services at an in-network ambulatory surgical center.You have been asked to pay a $310 copayment for each cataract surgery. The total amount you owe is $620 ($310/surgery x 2 surgeries = $620). Cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forcataract surgery provided on August 15, 2019 and August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 22, 2018.
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 the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on October 22, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were available in-network.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 forthe medical services provided to the enrollee by an out-of-network provider on June 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 3, 2019 to August 23, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the enrollee only presented with their Medicare card and that is the insurance you billed, which was Medicare. You also say that your admissions department did not know that this enrollee needed an authorization to stay with you.The Plan denied your request. The Plan says there were no medical records or insufficient medical records received to make a clinical determination.
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 pay for the skilled nursing services. Our reviewer says that daily skilled services are unable to be determined. Our physician reviewer found that medical necessity is unable to be determined based on the records that were provided by the appellant, as no supporting medical records were available for review.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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 3, 2019 to August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on March 9, 2019.You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order, lab requisition or medical records signed by the ordering physician stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Specifically, the record does not include a physician order or medical records signed by the ordering physician indicating what tests are to be performed. Therefore, we decided that the Plan does not have to pay for a drug test (G0483) provided on March 9, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the records do not state that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (J0897)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the SoClean 2 CPAP sanitizer purchased from the provider on April 26, 2019.You asked the Plan to reimburse you fora SoClean CPAP cleaner and sanitizer device. You say that it is medically necessary to have this device. The Plan denied your request. The Plan says the SoClean CPAP cleaner is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to reimburse you for the SoClean 2 CPAP sanitizer purchased from the provider on April 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Myriad myRisk testing rendered to the enrollee on September 20, 2019.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 testing is not covered.The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests.We looked at the file and Medicare rules. The test at issue was not approved through the MolDx program for the date of service at issue.Therefore, we decided that the Plan does not have to pay forthe Myriad myRisk testing rendered to the enrollee on September 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3.5 hours of additional home health aide services per week.You asked the Plan to pre-approve3.5 hours of additional home health aide services per week. 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 HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 3.5 hours of additional home health aide services per week. Our reviewer says that the services are not medically necessary. Our physician reviewer found based onavailable records, you do not meet criteria for coverage of the additional requested home health aide hours. The records do not indicate that you are receiving home health skilled nursing or therapy. The records do not show the additional requested home health aide services are reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. The records do not support the need for additional home health aide hours.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3.5 hours of additional home health aide services per week have not been met.Therefore, we decided that the Plan does not have to pre-approve3.5 hours of additional home health aide services per week.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lumbar epidural steroid injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested services have been found to be not medically necessary.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found it is not reasonable to repeatan injection that has not produced significant pain relief. The requested procedure 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 the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea lumbar epidural steroid injection for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for PT services. You say that the services were medically necessary. The Plan denied your request. The Plan says there is no authorization on file for the PT services in question.
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 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 medical services provided on May 24, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ophthalmology services provided on October 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forophthalmology services. You say that the enrollee currently resides at the nursing facility and relies on the facilities staff for all of his needs.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 ophthalmology services provided on October 16, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveHereditary Cancer Panel Testing for the enrollee.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessaryThe 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 testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a diagnosis ofbreast cancer and reports several family members with cancer history. The plan approved testing for BRCA 1 and BRCA 2, a subset of the genes tested in the requested panel. The remainder of the requested panel test for genetic errors that may cause an increased risk of cancer. The enrollee does not have specific symptoms or an outlined treatment plan pending the results of these other panel tests. The criteria as outlined in the LCD are not met. Medical necessity criteria is not met.
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 Plandoes not haveto pre-approveHereditary Cancer Panel Testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vision services provided on August 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forvision services. You say that due to a clerical oversight the prior authorization was not obtained, but the laser procedure to the right eye was necessary.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to 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 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 vision services provided on August 12, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is needed for the evaluation and treatment of cholecystitis.The Plandenied your request. The Plansaysthere are services available in-network.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 noexception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral for an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 24, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent nursing facility care provided on October 24, 2019.