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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says there is no rationale currently for approving this admission.The Plan must follow Medicare rules. The rules say that Medicare paysfor 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 admission. Our reviewer says that the requested admission is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee does not require skilled nursing or therapy services on a daily basis.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Chest X-ray (71046) provided on October 15, 2019.
You asked the Plan to pay for the chest x-ray. You say that the chest x-ray was medically necessary. The Plan denied your request. The Plan says there was no symptoms to indicate the need for the X-ray.
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 pay for the chest x-ray. Our reviewer says that The X-ray was not medically necessary. Our physician reviewer found per the reviewed documentation there is an absence of signs or symptoms indicating a need for the test. There was no specific clinical rationale for the chest x-ray. 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 chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a Chest X-ray (71046) provided on October 15, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiogram (93307).You asked the Plan to pre-approvethe transthoracic echocardiogram. You say that the echocardiogram is medically necessary.The Plan denied your request. The Plan says that rules for coverage are not met.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 transthoracic echocardiogram. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has hypertension, a murmur on physical exam concerning for possible aortic valve stenosis and electrocardiographic abnormalities suggestive of possible old inferior wall infarction. In this circumstance an echocardiogram both to evaluate a heart murmur and to assess wall motion/ejection fraction is reasonable and appropriate.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the transthoracic echocardiogram have been met.Therefore, we decided that the Plan has to pre-approvea transthoracic echocardiogram (93307).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve Botox injections.You asked the Plan to pre-approveBotox. You say that Botox is the only thing that has worked.The Plan denied your request. The Plan says you are not having 15 or more headaches per month.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox. Our physician reviewer found that you have 9-10 migraine headaches per month. The documentation does not support that Botox is medically reasonable and necessary. You do not meet the coverage criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the enrollee was enrolled in the hospice program.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 forthe services provided to the enrollee on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology treatment at the tertiary level of care to be provided by a Medical Group.You asked the Plan to pre-approveoncology treatment. You say that this was the provider recommended to you for your condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not need to be treated at the tertiary level of care and can be treated by a non-tertiary specialist. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 oncology treatment. Our reviewer says that you do not meet the Medicare criteria for treatment at the tertiary level of care at this time. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet your needs through the approved referralThere is nothing unique about your condition that would make it medically necessary for you to see the requested tertiary level of care provider. The Plan has shown that they have non-tertiary providers available who meet the standards of care required fortreatment of your 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 oncology treatment at the tertiary level of care have not been met. Therefore, we decided that the Plan does not have to pre-approveoncology treatment at the tertiary level of care to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the omalizumab injections provided from July 24, 2019 through September 18, 2019.
You asked the Plan to waive the coinsurance for the omalizumab injections. You say that you were not informed of the high coinsurance. You say that you would have declined going if you knew the cost. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Part B covered drugs at a network provider. You have been asked to pay a total of $2,667.76 for the omalizumab injections. The omalizumab injections falls within the "Medicare Part B prescription drugs" 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 coinsurance for the omalizumab injections provided from July 24, 2019 through September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pre-approve an UPWalker Lite.You asked the Plan to pre-approvean UPWalker Lite. The Plan denied your request. The Plan says that your doctor does not indicate the reasons why this specific walker is necessary for your condition.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 an UPWalker Lite. Our reviewer says that an UPWalker Lite is not considered medically reasonable and necessary in this case. The documentation does not reveal why this walker is necessary over a standard walker. There is no evidence that a standard walker would not meet your needs. The UPWalker Lite appears to exceed your medical need and there is no evidence that the requested device is superior or more medically appropriate for your needs than a standard walker alternative. Our physician reviewer found that your condition does not meet criteria for coverage of an UPWalker Lite.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an UPWalker Lite have not been met.Therefore, we decided that the Plan does not have to pre-approvean UPWalker Lite
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for endocarditis and end-stage renal disease. The enrollee has completed a prolonged course of antibiotics and is receiving his routine hemodialysis. The enrollee was apparently transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 1, 2019.You asked the Plan to pay forthe genetic testing. You say that the services were crucial in the diagnosis of the enrollee's medical condition.The Plan denied your request. The Plan must follow Medicare rules. Medicare rules say that  the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentationThe file shows that the enrollee received JAK2 V617F gene testing (CPT Code 81270). We looked at the file and Medicare rules. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrolleeat the time of service. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forthe genetic testing provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve internal canaloplasty provided on October 2, 2019.You asked the Plan to pre-approveinternal canaloplasty. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the effectiveness of this procedure has not been established.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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve internal canaloplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.Our physician reviewer found the records show no indication that canaloplasty would offer better treatment than standard surgical treatment for the enrollee's condition. The standards of surgical treatment are trabeculectomy, laser trabeculoplasty, and placement of a tube shunt. There may be a potential benefit of canaloplasty as an effective surgery to lower intraocular pressure with fewer complications than those associated with trabeculectomy, however, the data to support this position is still limited.The studies evaluating canaloplasty do not provide a clear picture of how the procedure compares directly with the standard surgical treatments in terms of outcome.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of internal canaloplasty have not been met.Therefore, we decided that the Plan does not have to pre-approveinternal canaloplasty provided on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea low dose CT scan for the enrollee.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. ThePlan says the records do not show that the criteria has been met.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 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 the enrollee is not asymptomatic, and is not a current smoker or one who has quit within the last fifteen years. The enrollee quit 30 years ago. 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-approvea low dose CT scan for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe interpretation of the PET/CT scan provided on November 6, 2019.You asked the Planto pay forthe PET/CT scan interpretation. You say that this should be paid and the facility has the records to support medical necessity.The Plandenied your request. The Plansaysthis claim cannot be paid as more than three subsequent PET scans have been provided and this claim was not billed with the KX modifier to signify that criteria for additional PET scans are met.The Plan must follow Medicare rules. Medicare rules say that claims for PET imaging for subsequent anti-cancer management when three scans have already been performed must include modifier KX to indicate that criteria for the medical necessity of more than three scans are met. In this case, more than three subsequent PET scans have been provided and no KX modifier was used on this claim.Therefore, we decided that the Plandoes not haveto pay forthe interpretation of the PET/CT scan provided on November 6, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 30, 2019.You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says that 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, hasbeen 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 servicesat 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 genetic testing provided on September 30, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the abdominal aortic ultrasound provided on October 23, 2019.
You asked the Plan to waive the copayment for the abdominal aortic ultrasound. You say that this was a preventive aortic screening and is 100% covered. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that there is no coinsurance, copayment, or deductible for members eligible for the abdominal aortic aneurysm preventive screening.
The Plan says you must pay a $107.13 copayment for the abdominal aortic ultrasound. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the abdominal aortic ultrasound. The medical record show an abdominal aortic aneurysm screening was performed and not a diagnostic ultrasound. Therefore, we decided that the Plan has to waive the copayment for the abdominal aortic ultrasound provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 24, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the services were not authorized.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 laboratory services. 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 laboratory services provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided to the enrollee on October 5, 2018.You asked the Plan to pay forthe x-ray. 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 test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided to the enrollee on October 5, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 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 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 physician's services provided on November 13, 2019.