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

We decided that the Plandoes not haveto pre-approvedermaPACE shockwave therapy for the enrollee.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered investigational and not medically necessary.The Plan must follow Medicare rules. Medicare rulessay 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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found the provider requested dermaPACE shockwave therapy for the care of the wound. Review of the literature notes observational and small randomized trials have been studies. The literature does not support this treatment widely accepted by controlled, double blind studies. Without the support, the treatment is considered investigational and not medically 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 therapy have not been met.Therefore, we decided that the Plandoes not haveto pre-approvedermaPACE shockwave therapy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CALR and JAK2 genetic testing for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CALR and JAK2 testing is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a several-year history of leukocytosis, which is characterized by neutrophil predominance. The enrollee's hematologist/oncologist documents that an unlikely diagnostic possibility is that the enrollee has an underlying myeloproliferative neoplasm. The sequential genetic testing approach established by the Medicare rules has not been followed in this case. The testing is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve CALR and JAK2 genetic testing for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on November 6, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 forlab services provided to the enrollee on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 27, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. The documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 3, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says that there is no
network deficiency for the services, and alternate network providers were found.
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 OON services. Therefore, we decided
that the Plan does not have to pay for the lab services provided on September 3, 2019 by an out of network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual physical exam rendered to you on December 9, 2019.You asked the Plan to pay for these services. You say that The Plan denied your request. The Plan says you exceeded the benefit limit.The Plan must follow Medicare rules. The rules say that Medicare covers one physical exam per lifetime. The Plan contract says that an annual physical exam is covered once every 12 months.We looked at the file and Medicare rules. The file shows that you previously had an annual physical exam on April 1, 2019 for which the Plan approved and paid. The physical exam on December 9, 2019 was performed less than12 months from your previously covered physical exam.Therefore, we decided that the Plan does not have to pay for the annual physical exam rendered to you on December 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve endovenous radiofrequency ablation.You asked the Planto pre-approvethe treatment. You say that this is medically necessary.The Plandenied your request. The Plansaysthe guidelines expect a six week trial of conservative therapy, such as compression stockings, exercise, or weight reduction.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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no recent documentation of symptoms attributable to varicose veins. There is no recent documentation of satisfactory arterial perfusion to the lower extremities. There is no recent documentation of reflux or of deep venous patency. And, as noted by the health plan, there is no documentation of a recent concerted effort at conservative treatment. In essence, none of thecoverage criteria are met including the requirement for an effort at conservative treatment.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 treatment have not been met.Therefore, we decided that the Plandoes not haveto pre-approveendovenous radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8, 2019 to October 9, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department of the acute hospital with a right upper extremity thrombosed arterio-venous fistula. The enrollee was alert and in no distress with an initial blood pressure of 174/105 in the emergency room. The remainder of the enrollee's exam and vital signs were normal except for faint right lower lobe crackles. The enrollee's labs were remarkable for a potassium level of 5.7. The enrollee was admitted to inpatient status and underwent a balloon angioplasty of the fistula on 10/08/2019 with no complications reported and he had dialysis afterwards. The documentation does not support that the enrollee's necessary hospital care (including earlier Emergency Department and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8, 2019 to October 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy and room & board services provided from September 21, 2019 to September 23, 2019.You asked the Plan to pay forthe physical therapy and room & board services. You say that you were told that the enrollee would be discharged on September 28, 2019, but were later told that that the enrollee would be discharged home on September 21, 2019. You also say that an unusable and unsafe bed was dropped off.The Plan denied your request. The Plan says the services you received were not authorized and are excluded from coverage.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 physical therapy and room & board 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 physical therapy and room & board services have not been met.Therefore, we decided that the Plan does not have to pay forthe physical therapy and room & board services provided from September 21, 2019 to September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for ab work. You say that the lab sample was sent to your facility. You say that you don't ever see the patient.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the ordering provider is also out-of-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 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 lab work provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 25, 2019 to the enrollee by an out of network (OON) provider. 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 the services were rendered by an out-of-network provider without prior authorization.
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 November 25, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for gradient pressure appliances (E0673 and E0666) and orthotic management training (97760) provided on October 10, 2019.You asked the Plan to pay for the gradient pressure appliances and orthotic management training. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the records do not support the services billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Additionally, the records do not indicate that orthotic management training was rendered on this date of service.Therefore, we decided that the Plan does not have to pay forgradient pressure appliances (E0673 and E0666) and orthotic management training (97760) provided on October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Upper Extremity (73220).
You asked the Plan to pre-approve the MRI. You say that the MRI medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
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 MRI is not medically necessary. Our physician reviewer found while ongoing evaluation is medically necessary and reasonable, it is unclear that MRIs of the entire right upper extremity, right wrist and right hand are the best course of action. 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 Magnetic Resonance Imaging (MRI) of the Upper Extremity (73220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical repairs.
You asked the Plan to pre-approve the electric repairs. You say that you have lighting in your home that is not working which puts you at risk for injury and prevents you from taking care of yourself. The Plan denied your request. The Plan says this is not covered by the plan since there is no evidence that these repairs are needed to complete tasks to maintain your health.
The Plan must follow Medicare rules. Medicare rules say that services that are not reasonable and necessary to treat or diagnose an illness or injury are not covered. In this case, although electrical repairs may be helpful to certain tasks to maintain your health, these do not directly contribute to the treatment of a medical condition. As such, this is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve electrical repairs.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 29, 2019 to August 27, 2019.
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 Long-Term Care in a SNF is not a covered benefit under the enrollee's Medicare plan.
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 July 29, 2019 to August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism purchased out of network on July 9, 2019.
You asked the Plan to pay for out of network equipment. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network equipment.
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 a seat lift mechanism purchased out of network on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 19, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation provided does not supported this code.
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. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low profile cushion (E2622) to be provided by an out-of-network provider.You asked the Plan to pre-approve the cushion. You say that the cushion is medically necessary.The Plan denied your request. The Plan says there are network providers that can provide the requested equipment.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 low profile cushion (E2622) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on January 25, 2019.You asked the Plan to pay forthese drugs. You say that you did not self-administer any drugs.The Plan denied your request. The Plan says that self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided on January 25, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.