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

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.

You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 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 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 services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for cardiovascular risk assessment services provided to the enrollee on October 28, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says that Medicare guidance says Medicare denies coverage for all cardiovascular-respiratory risk assessment panels. You can find the guidance in the Medicare Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk Assessment (L36139) or (L36523), Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), and Medicare Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk (L36129), and the Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services, Code of Federal Regulation 42 CFR 410, Subpart B - Medical and Other Health Services (screening tests).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Medicare relations used by the Plan are not in the coverage jurisdiction for the enrollee's home state of Georgia or the provider lab location of Colorado, and therefore do not apply. Therefore, we decided that the Plan has to pay for cardiovascular risk assessment services provided to the enrollee on October 28, 2020. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81185, 81479) provided on October 22, 2020. You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81185, 81479) provided on October 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that you were not informed that a trip is considered one-way when going to the doctor's, meaning a total of two trips. The Plan denied your request. The Plan says this request exceeds the maximum count allowed per period.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on March 16,
2021.

You asked the Plan to pay for the outpatient office visit. You say that you would like reconsideration because
you were a new patient and would not be able to see this provider without being given a new patient office or
outpatient visit. The Plan denied your request. The Plan says services other than manipulations are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the need for skilled therapy had ceased. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a biopsy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a biopsy. You say that you feel more comfortable going to this center for the biopsy. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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-approve a biopsy to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia syringe 60mg/ml.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria were not followed.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates the enrollee has osteoporosis. The record indicates that the requested drug is a new start. The record indicates that the enrollee has not tried and failed an intravenous bisphosphonate. The prescriber has not indicated that an intravenous bisphosphonate would not be appropriate for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia syringe 60mg/ml.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve compression stockings. You say that these stockings are necessary to prevent sores and blood clots. The Plan denied your request. The Plan says these stockings are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following a motor vehicle crash. The enrollee, who has diabetes, hypertension, and renal failure, was found to have endocarditis and sepsis. The enrollee is clinically unstable. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on March 15, 2021.
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport (A0428). You say that that the emergency medical technician concluded that the enrollee required further medical care due to an infection. The Plan denied your request. The Plan says prior authorization was required and not obtained.
The Plan contract says that prior authorization is required for non-emergency transport.
We looked at the file and the Plan's rules. The file shows that prior authorization was not obtained for the ambulance transport. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428) provided on March 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 16, 2020.

You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.

The Plan must follow Medicare rules. Medicare rules say that PTA services cannot be covered when they are provided/billed incident to a physician/NPP service. 

We find that CPT code 97110 is not supported in the record. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules to LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are medically stable with no evidence of need for supervision by a physician or are you in need 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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.of acute rehab nursing care. You may benefit from further physical therapy, but you do not require an intensive therapy program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ramp

You asked the Plan to pre-approve a ramp. You say that your doctor is insisting that you need the ramp due to your injuries. Without the ramp this will cause more harm. The Plan denied your request. The Plan says a ramp is considered safety equipment and does not serve a medical purpose and is not covered.

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 pre-approve a ramp
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the caries risk assessment and documentation, with a finding of high risk (D0603) provided on February 27, 2020.

You asked the Plan to pay for the periapical x-rays and the caries risk assessment and documentation. You say that this visit was necessary to determine your future dental work. The Plan denied your request.

The Plan says periapical x-rays are not listed as covered services. The Plan says that caries risk assessment and documentation is not listed as a covered service either. The Plan also says that you were not enrolled in the optional supplemental dental rider on the date of service in this case and therefore those benefit would not apply.

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 pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the caries risk assessment and documentation, with a finding of high risk (D0603) provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from December 9, 2020, to December 13, 2020.
You asked the Plan to waive the deductible for an inpatient hospital stay. You say that the enrollee should only be responsible for the copayment and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan says that there is a $1,000 deductible for inpatient hospital care. The enrollee had an inpatient hospital stay from December 9, 2020, to December 13, 2020. The record shows that the enrollee had paid $0 toward the $1,000 deductible prior to receiving the services. Therefore, the enrollee is responsible to pay the $1,000 deductible. The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000
deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time an inpatient hospital stay was received on December 9, 2020 to December 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from December 9, 2020, to December 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health admission.
You asked the Plan to pre-approve inpatient behavioral health admission. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient behavioral health admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review the of records provided, for the admission of this enrollee does not meet the criteria for acute inpatient mental health/detoxification treatment as this enrollee was not shown to be a danger to himself or others. The enrollee was without agitation or aggression and without perceptual disturbance including auditory, visual hallucinations or delusions. This enrollee was not showing any acute symptoms suggesting a high-risk of withdrawal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 4 very heavy duty power wheelchair (K0871). 
 
You asked the Plan to pre-approve a Group 4 power wheelchair. You say that the requested item is a necessity 
for the enrollee's care. The Plan denied your request. The Plan says rules for power wheelchairs have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that Group 4 power wheelchairs are not reasonable and 
necessary. 
 
The file shows that the request is for a Group 4 power wheelchair. This means that Medicare rules for coverage 
of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 4 very 
heavy duty power wheelchair (K0871).