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

We decided that the Plan does not have to pre-approve the Guardant360 test for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is needed in order to help treat the enrollee for breast cancer The Plan denied your request. The Plan says the enrollee does not have enough quantity of tissue for invasive biopsy/testing.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have breast cancer, which was initially diagnosed in 1988. Since that time, the enrollee has had recurrences and developed metastasis despite receiving surgery, chemotherapy, radiation therapy and hormone therapy. It is unclear how genetic testing will change the enrollee's diagnosis or treatment plan. Panel testing, which tests for genes unrelated to breast cancer and/or for which there are no associated therapies is not medically necessary. The documentation does not support that the requested testing is medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the Guardant360 test for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not need skilled services at least 5 days a week.
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. Skilled nursing facility services beyond May 29, 2020 were requested. 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 continued services. Our physician reviewer found that the enrollee is at contact guard assist for transfers, and at supervision to minimal assist for activities of daily living. the provided medical records do not indicate a need for skilled nursing or skilled therapy services. The enrollee does not require skilled 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2019 through September 15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2019 through September 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 the medical services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 13, 2019 to November 19, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the patient was admitted out of concern her symptoms were attributed to an escalating condition. The Plan denied your request. The Plan says that the enrollee could have been treated in observation care.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee arrived at the emergency room via ambulance with concerns over psychosis and paranoia after she made repeated calls to law enforcement. Her thyroid stimulating hormone level (TSH) was elevated to 55 mU/L and endocrinology recommended restart of her already prescribed Levothyroxine 88 mcg. Skilled nursing facility or respite placement were attempted while the enrollee was in the emergency room but unsuccessful. She had no skilled needs to justify a skilled nursing facility placement. She was admitted to the hospital while awaiting family to arrive. A 1:1bedside sitter was required to manage her safety. Geriatric Psychiatry was consulted and Risperidone was added to her medication regimen on the final day of her stay. The eventually was eventually discharged home when considered medically stable with her son on November 19, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 13, 2019 to November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genetic testing panel provided on March 22, 2019.
You asked the Plan to pay for genetic tests. You say that it is the responsibility of the ordering physician to determine medical necessity for testing. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were not medically necessary.
The Plan follows Medicare rules. Medicare rules say that next generation sequencing testing may be covered by Medicare if certain, 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 pay for genetic tests. Our reviewer says that this
testing does not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee has early stage (Stage 1) cancer. Molecular profiling next generation sequencing is not indicated for the enrollee's condition as unlikely to alter outcomes. Standard diagnostic and prognostic testing with fluorescence in situ hybridization (FISH) and other molecular markers are indicated but next generation sequencing is not considered a standard of care. Therefore, this testing was not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for a genetic testing panel provided on March 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a home ventilator to be used as a BiPAP device is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our physician reviewer found that the enrollee does not have one of the following covered diagnoses: neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. There is not adequate evidence that nocturnal ventilatory support is beneficial for interstitial lung disease. Further, Medicare does not cover a home ventilator when used as a BiPAP device. Therefore, a home ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92004) and eye refraction (92015) provided January 21, 2020.
You asked the Plan to waive the copayment for the eye exam and refraction services.. You say that you had an eye exam and now you have received a billing statement that you owe a copay however on page 71 of the EOC says you can have an eye exam without any copay. The Plan denied your request. The Plan says the copayment has been applied correctly as this was a diagnostic exam and not a routine exam.
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 $10 for Medicare covered physician services. Consultation, diagnosis and treatment by a specialist is listed as covered services under Physician/Practitioner services, including doctor's office visits. You have been asked to pay $10 for the eye exam and refraction services. The eye exam and refraction services fall within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for comprehensive eye exam (92004) and eye refraction (92015) provided January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient visit. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 the medical services provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the immune globulin infusion provided on January 3, 2020.
You asked the Plan to waive the copayment for the infusion. You say that you were led to believe you would not have any costs for these infusions in your enrollment process. The Plan denied your request. The Plan says that you were charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay less than a 20% coinsurance for the infusion. The infusion falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay less than the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the immune globulin infusion provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee only had 40% relief from previous injection.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has diagnoses of cervicalgia, migraines, lumbar spondylosis, and chronic pain, currently on opiates. The enrollee had a medial branch block which resulted in 40% pain relief. A second MBB has been requested. The records do not show that there was a positive response of at least 80% relief of primary pain or at least 50% improvement in the ability to perform previously painful movements from the first MBB. Therefore, the requested medial branch block medically is not reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks (MBBs).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on November 7, 2019 to November 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for assisted living services. You say that these services were provided in an assisted living facility. You say that it is the facility's responsibility to get prior authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that a doctor must certify that the member needs home health services and will order home health services to be provided by a home health agency. The Plan says that the member must be homebound, which means leaving home is a major effort.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 assisted living services provided on November 7, 2019 to November 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee requires a respiratory therapist to set him up and maintain his compliance daily. The Plan denied your request. The Plan says medically necessary care is available in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items and 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 durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for teeth #'s 21 and 22.
You asked the Plan to pre-approve the core buildup. You say that it is felt that these services are necessary and should be approved. The Plan denied your request. The Plan says based on the documentation, it was decided that the partial dentures, crowns, and extractions are necessary and approved. However, no coverage is available for code D2950.
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 core buildup for teeth #'s 21 and 22.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee has weakness in the lower extremities. The Plan denied your request. The Plan says there are network providers available for the requested services.
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 and facility in this case are not network providers 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 OON services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on December 6, 2019.
You asked the Plan to pay for this 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 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 Plan contract also says that chiropractic care requires both are referral and prior authorization. You are 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 these 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 chiropractic services provided to the enrollee on December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 17, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on December 17, 2019.