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

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) scan.You asked the Plan to pre-approvean MRI scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested MRI scan is not medically necessary.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 an MRI scan. Our reviewer says that the documentation does not support that the requested MRI scan is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of low back pain. There are also no documented changes in the enrollee's symptoms. Although a recent x-ray was performed and reviewed, there is no indication provided for a new magnetic resonance imaging scan, as this was done two years ago and there is no noted change in the enrollee's symptoms. Therefore, the enrollee does not meet criteria for the requested 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 an MRI scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Freestyle Libre therapeutic continuous glucose monitor (CGM).You asked the Plan to pre-approvethe CGM. You say that this device is medically necessary.The Plan denied your request. The Plan says prior authorization criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive genomic profile testing provided on May 23, 2020.You asked the Plan to pay forgenetic testing. You say that this testing is covered by Medicare and must be covered by the Plan.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service May 23, 2020. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forcomprehensive genomic profile testing provided on May 23, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient services provided from October 19, 2019, to October 25, 2019.You asked the Plan to pay forinpatient services. You say that the services that were provided were necessary.The Plan denied your request. The Plan says based upon the Uniform Hospital Discharge Data Set (UHDDS) rules, the corrected DRG 438 Disorders of pancreas exceptmalignancy with MCC is more appropriate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 871 is defined as septicemia or severe sepsis without MV>96 hours with MCC. In this case, you billed the services provided October 19, 2019, to October 25, 2019 with DRG 871. 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 inpatient services. Our reviewer says that the DRGis not supported by the clinical records. Our physician reviewer found there was insufficient evidence that the patient had sepsis. Therefore, the DRG of 871 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 871.Therefore, we decided that the Plan does not have to pay forthe inpatient services provided from October 19, 2019, to October 25, 2019with DRG 871
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair (E0240).You asked the Plan to pre-approvethis item. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair (E0240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D4341).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approvedental services (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided  by an out of network provider.You asked the Plan to pay forthe physician services. You say that the services were medically necessary so the Plan should pay this claim.The Plandenied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providersonly 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 services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe physician services provided by an out of network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrolee is being treated for lumbar spinal stenosis with neurogenic claudication. The requested Superion spacer is considered experimental in nature and not the standard of care over the gold standard of lumbar laminectomy. The services are therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not haveto pre-approvea Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia provided by an out-of-network provider.You asked the Plan to pay foranesthesia. You say that the enrollee did not need authorization. You say that the claim should be paid.The Plan denied your request. The Plansays this provider is not a network provider with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider and facility 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 foranesthesia provided by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient surgery provided by a participating provider on May 22, 2020, to July 9, 2020.You asked the Plan to waive the copayment foran outpatient surgery. You say that you do not agree with the Plan not paying anything.The Plan denied your request. The Plan says the correct copayment has been applied.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 $260 copayment for outpatient surgery/in-network. You have been asked to pay $137.24 which is less than your copayment amount of $260for an outpatient surgery. The total amount you are being asked to pay is $1,646.88 ($137.24 x 12 visits = $1,646.88). Since the allowed amount of $137.24 is less than your copayment you are responsible for the full allowed amount. An outpatient surgery falls within the outpatient surgery/in-network 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 foran outpatient surgery provided by a participating provider on May 22, 2020, to July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance imaging (MRI) of the pelvis (72195), lab testing (82565) and Glucagon injection (J1610) provided on July 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe MRI, lab and drug services. You say that these services were medically necessary.The Plan denied your request. The Plan says they do not cover services provided out of network, except in limited circumstances. The services in question were not urgent or emergent and they were not pre-approved.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 topay forthe magnetic resonance imaging (MRI) of the pelvis (72195), lab testing (82565) and Glucagon injection (J1610) provided on July 17, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says based on Medicare guidelines, the IRFservices you and/or your provider are requesting do not meet the requirements for approval.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 that 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. The enrollee was admitted for a stroke with left sided weakness in December 2020. He has been discharged home with home health services and has ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs.The enrollee does 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-approveIRFadmission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group three power wheelchair and accessories.You asked the Plan to pre-approvea group three power wheelchair and accessories. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3.Congenital skeletal deformity.The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approvea group three power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea hand held shower, bath tub rails and bath shower chair.You asked the Planto pre-approvethe items. You say that this is medically necessary.The Plandenied your request. The Plansaysthese items are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The items at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to thegeneral public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea hand held shower, bath tub rails and bath shower chair.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless forthe emergency department visit provided .You asked the Plan to hold you harmless forthe emergency department visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services billed are a duplicate to services already processed.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were providedthe emergency department visit by a contract provider. The file does not show that the Plan provided notice that the emergency department visit would not be covered. In addition,while this claim may be a duplicate to a previously processed claim, the enrollee should not be responsible for billing errors of the participating provider. Under Medicare rules, this means the emergency department visit is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmless forthe emergency department visit provided .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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis coded L0650 provided .You asked the Plan to pay forthe lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the items rendered arenot supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code L0650 is not supported in the medical record. Specifically, the documentation does not include a claim for the ordering physician. A relationship between the enrollee and the ordering physician has not been supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis coded L0650 provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that you need therapy and care.The Plan denied your request. The Plan says the admission is not medically necessary.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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on February 1, 2021,with septic shock due to COVID and urinary tract infection. You received oral medications and had stable vital signs. You had a feeding tube placement. You received physical, speech, and occupational therapy in the hospital. You are dependent with functional mobility and activities of daily living. You have no skilled therapy needs. You have skilled nursing needs but do not require skilled nursing services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.
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-approvea skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided  by an out of network (OON) provider.You asked the Plan to pay forthese 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 withoutprior 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 referring provider 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 forthe medical services provided  by an out of network (OON) provider