Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound examination of heart (93306) provided on June 12, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the ultrasound examination of heart. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 ultrasound examination of heart (93306) provided on June 12, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of brow ptosis and a blepharoplasty of the lower
lid.

You asked the Plan to pre-approve repair of brow ptosis and a blepharoplasty of the lower lid. You say that the
requested repair of brow ptosis and a blepharoplasty of the lower lid is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet criteria for the requested repair of brow ptosis and a
blepharoplasty of the lower lid.

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 repair of brow ptosis and a
blepharoplasty of the lower lid. Our reviewer says that the enrollee does not meet criteria for the requested
repair of brow ptosis and a blepharoplasty of the lower lid. Our physician reviewer found the enrollee is with
complaints of tired eyes and worsening vision. Exam shows dermatochalasis without ptosis and MRD1 of 2mm
bilaterally. Eyebrows are at orbital rim. Superior visual field testing with and without lid taping was performed
and showed improvement of the superior visual field with lids elevated. External photos provided demonstrate
dermatochalasis with hooding of the lid margin and lash line. The brows sit at the orbital rim with frontalis
muscle relaxed.

Based on the photos provided, the enrollee does not have brow ptosis. She has visually significant
dermatochalasis and bilateral blepharoplasty would be medically indicated for this condition. There is no
medical indication for lower lid blepharoplasty as this is considered a cosmetic procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of repair of brow ptosis and a blepharoplasty of the lower lid have not been met.
Therefore, we decided that the Plan does not have to pre-approve repair of brow ptosis and a blepharoplasty of
the lower lid.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by on July 23, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place and did not call for this service. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided on May 8, 2020, to July 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for telehealth services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 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 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 telehealth services provided on May 8, 2020, to July 13, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (C2624, 33289).
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device (C2624, 33289).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided November 22, 2019, to November 28, 2019.
You asked the Plan to pay for the inpatient hospital care. You say that the inpatient hospital care was medically necessary and reasonable. The Plan denied your request. The Plan says the inpatient care provided was unauthorized post-stabilization care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our reviewer says that the inpatient hospital care provided was not medically necessary. Our physician reviewer found the was no documentation provided necessitating post-stabilization care services at the non-contract Plan facility after 11:59 on November 24, 2019. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided November 22, 2019, to November 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission to a SNF.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs physical therapy to become strong enough and sure enough to be in an assisted living facility. The Plan denied your request. The Plan says the SNF admission you have requested does not meet Medicare guidelines.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission to a SNF.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 24, 2020, to
June 10, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF
continuation was not medically reasonable.
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 the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from May 24, 2020, to June 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is not medically necessary. The Plan denied your request. The Plan says this is medically necessary.
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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found Medicare (per the applicable NCD) covers a PET/CT scan of the brain in the evaluation of memory problems to differentiate between Alzheimer's Dementia and Fronto Temporal Dementia. In this case, the enrollee is said to have complaints of memory problems. The NCD states that " FDG-PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD ". In this case the medical records indicated that the enrollee had a normal MMSE score. She was not noted to meet the diagnostic criteria for both AD and FTD. Inasmuch it cannot be said that the enrollee would meet the requirements for performance of a PET scan of the brain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2020.
You asked the Plan to pay for the laboratory 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 payable.
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 the laboratory services provided on April 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that the benefit is needed for the crown. The Plan denied your request. The Plan says this is not a covered service.
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 a core buildup, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the cervical and lumbar spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation submitted with the appeal request does not demonstrate medical necessity.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has been diagnosed with left cervical radiculopathy and left lumbar radiculopathy. Under consideration is a request for cervical spine MRI and lumbar spine MRI. Current evidence based medical guidelines would not support MRI at this time. Medical records submitted with this request do not include a current pain or functional assessment, clinical findings including a cervical or lumbar spine exam or upper/lower extremity neurologic exam, indications for the requested imaging, or discussion of tried/failed conservative treatment. Therefore, this request for cervical spine MRI and lumbar spine MRI is not medically reasonable and necessary at this time. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the cervical and lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial denture (D5213) and crown (D2740).
You asked the Plan to pre-approve the partial denture and crown. You say that you would like the Plan to pay for the dental services requested. The Plan denied your request. The Plan says your 2020 supplemental dental benefits have been exhausted for the services you are requesting.
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 partial denture and crown when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. The case file indicates that the plan covers one partial denture procedure every five years and two crown procedures every year. According to the record, you have exhausted the partial denture and crown benefit for 2020. Based on this information, we decided that the Plan's rules for coverage of the partial denture and crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the partial denture (D5213) and crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral surgery procedure (D7999).
You asked the Plan to pre-approve the oral surgery procedure. You say that you would like this service covered because you are in pain and cannot eat. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 an oral surgery procedure (D7999).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 30, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not in hospice at the time of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before the end of that month.
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on July 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the upper extremity joint.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not support the pain is unresponsive to conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the physical exam does not reveal a red flag such as weakness, absent reflex etc. to mandate immediate MRI. In particular, the notes show a plan for PT which has not yet been attempted or completed. Absent a trial of PT with monitoring, the medical necessity of MRI right shoulder has not been established. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the upper extremity joint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 12, 2020.
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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services (92004, 92134) provided on May 28, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the vision services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says supplemental vision services must be received from a participating provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from a participating provider.
We looked at the file and the Plan's rules. The case file indicates that the vision services were received from a provider who is OON with the plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services (92004, 92134) provided on May 28, 2020, by an out-of-network (OON) provider.