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

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on September 1, 2020.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels.

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 cardiovascular risk assessment, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include clinical information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on September 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the follow-up visit provided by an out of network (OON) provider.

You asked the Plan to pay for the follow-up visit. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 follow-up visit provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 13, 2020.

You asked the Plan to pay for the dental service. You say that you received a simple extraction on the date of service, not a surgical extraction. The Plan denied your request. The Plan says surgical extractions are not covered. The Plan also says that you signed a treatment plan which lists a surgical extraction.

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, surgical extraction is not among those covered under this benefit. The record shows that you signed a treatment plan which lists a surgical extraction. The signed treatment plan shows that you were advised in advance that you would have a surgical extraction performed on the date of service. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids and accessories (V5298 x2, V5267 x2, V5266, V5267).

You asked the Plan to pay for hearing aids and accessories. You say that you were told that you would get some reimbursement even though the purchase was out-of-network. The Plan denied your request. The Plan says the items were received from a non-vendor provider and are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when the Plan vendor is used. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids and accessories have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids and accessories (V5298 x2, V5267 x2, V5266, V5267).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services provided by an OON provider.

You asked the Plan to pay for the initial hospital care services. You say that the treating provider depends upon
the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance
company. The Plan denied your request. The Plan says these services were rendered by an OON provider. The
Plan also says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided 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 initial hospital care services provided 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided by an out-of-network provider on September 3, 2020.

You asked the Plan to pay for x-ray services. You say that the diagnostic radiology procedures do not require authorization. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 x-ray services provided by an out-of-network provider on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on August 5, 2020.

You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. To report a CGP service, test providers should use CPT code 81479. 

We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported in the medical record. Specifically, the testing at issue is considered CGP testing and should be reported with 81749. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on August 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 18, 2020.

You asked the Plan to waive the copayment for the ER visit. You say that you were transferred to this ER and were informed there would only be one charge. The Plan denied your request. The Plan says the copayment 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 $90 for each Medicare-covered emergency room visit. 

You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you were treated in the ER. 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 the ER visit provided on December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.

You asked the Plan to pre-approve Entresto. The Plan denied your request. The Plan says Entresto falls under Part D coverage.

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 pre-approve Entresto.

Benefits for Entresto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee doe not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve a Zephyr endobronchial valve placement (31647, 31651).

You asked the Plan to pre-approve the endobronchial valve placement. You say that the procedure is medically
necessary. The Plan denied your request. The Plan says that this procedure is still unproven and is not
medically necessary.

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 endobronchial valve placement. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found clinical trials have demonstrated that, in appropriately selected patients, EBV
placement has benefits roughly comparable to surgical lung volume reduction, with less risk. The substantial
risk of pneumothorax requires a minimum 3-day hospital stay, but this risk is still less than for surgical
reduction. This procedure is no longer considered experimental or investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the endobronchial valve placement have been met. Therefore, we decided that
the Plan has to pre-approve a Zephyr endobronchial valve placement (31647, 31651).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Hyalgan. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee is noted to have knee pain. The documentation does not support that the enrollee has tried and failed Monovisc or Orthovisc. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee. Therefore, the enrollee does not meet criteria for the requested Hyalgan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening.

You asked the Plan to pay for the cardiovascular disease screening. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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 cardiovascular disease screening, 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 for the cardiovascular disease screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Detect (0012M).

You asked the Plan to pay for the CxBladder Detect. You say that you would like reconsideration because this service is medically necessary, and a Medicare covered benefit. The Plan denied your request. The Plan says this service does not meet Medicare's criteria of medically necessary and reasonable and cannot be approved.

The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0012M, non-coverage was reaffirmed by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder Detect have not been met. Specifically, this testing is not a covered benefit. Therefore, we decided that the Plan does not have to pay for CxBladder Detect (0012M).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Taltz.

You asked the Plan to pre-approve Taltz. The Plan denied your request. The Plan says this drug is self-administered. The Plan also says that this is a part D drug and not covered under the enrollee's Medicare Advantage only plan.

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 pre-approve Taltz.

Benefits for Taltz may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on
September 14, 2020.

You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the requested item was
legally and accurately prescribed by the physician. The Plan denied your request. The Plan says there was no
video or telephonic exam by the ordering physician to warrant the code billed.

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 a shoulder-elbow-wrist-hand orthosis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the Shoulder,
Right. The documentation in the case file does not support that the requested shoulder/arm orthosis was
medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would
reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for the
enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the
enrollee in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical
examination of the shoulder.

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 shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided
that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on September 14,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (76815) provided by an out of network (OON) provider.

You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was rendered out-of-networking, was not urgent, emergent or approved in advance.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ultrasound (76815) provided by an out of network (OON) provider.