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

We decided that the Plan does not have to pre-approve an implantable loop recorder (33285).You asked the Plan to pre-approvethe implantable loop recorder. You say that you would like reconsideration because the implantable loop recorder is appropriate due to the membershistory of stroke.The Plan denied your request. The Plan says the records do not show that the member has had a fainting event thought to be caused by irregular heart rhythm.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 implantable loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance of prolonged monitoring that has already been completed without evidence of atrial fibrillation, placement of an implantable loop recorder has not been shown to provide incremental outcomes benefit.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 implantable loop recorder have not been met.Therefore, we decided that the Plan does not have to pre-approvean implantable loop recorder (33285).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided on February 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate claim line.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The records show that CPT 71045 was previously paid by the plan for the date of service in question. The requested services were billed on a duplicate claim line and are not payable. The records do not support that an additional unit of CPT 71045 was provided on February 26, 2020. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 71045) provided on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to acute care for treatment of severe chronic obstructive pulmonary disease and respiratory failure. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator management, scheduled nebulizer treatments, and tracheostomy care, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provideron March 20, 2020.You asked the Plan to waive the copayment for an emergency room visit. You say that you were never treated for your pain. You say that you ended up leaving and they did nothing to help you. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since emergency roomservices were provided, the correct copayment has been applied. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 an emergency room visit provided by a participating provideron March 20, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that the requested medication is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy
exception has not been met.
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 Aranesp. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found based on the medical records provided
there is no indication that the plan's required drug would likely be less effective and/or likely have adverse
effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic services (G0463). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require 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 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 January 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty 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 contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the physician's services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cystourethroscopy (52287) provided on December 3, 2019.
You asked the Plan to pay for the cystourethroscopy. You say that you would like reconsideration because the
place of service billed was correct. The Plan denied your request. The Plan says it is inappropriate for 0580, a
home health service, to be rendered in an ambulatory surgical center.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 52287 is not supported in the record. Specifically, the revenue code reported for this
service is home health code 0580. This was billed for an ambulatory surgical center. It is inappropriate to bill a
home health service in an ambulatory surgical center. Based on this information, we decided that Medicare
rules for coverage of the cystourethroscopy have not been met. Therefore, we decided that the Plan does not
have to pay for cystourethroscopy (52287) provided on December 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided August 20, 2019 to December 18, 2019.You asked the Plan to pay for home infusion therapy. You say that other claims for this code have been paid.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.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 S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided August 20, 2019 to December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs rendered on January 14, 2020.
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 self-administered drugs are not a covered benefit.
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 for the self-administered drugs rendered on January 14, 2020.
Benefits for these services 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a cardiology follow-up visit. You asked the Plan to pre-approve the follow-up visit. The Plan denied your request. The Plan says that the visit is 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 the follow-up visit. Our reviewer says that the requested follow-up visit is not considered medically reasonable and necessary in this case. Our physician reviewer found that although the enrollee does not require intervention at this time, reasonably spaced clinical follow-up with a cardiologist for continued re-assessment of the mild valvular disease as well as
repeat and ongoing blood pressure evaluation is reasonable and warranted. Given the aortic insufficiency on echo, the threshold for treating SBP above 130 or diastolic above 80 would indeed be lower than usual and regular cardiology follow-up, and to assess this is both medically reasonable and 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 follow-up visit have not been met. Therefore, we decided that the Plan has to pre-approve a cardiology follow-up visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copays forthe ambulance transports provided on December 2, 2019.You asked the Plan to waive the copays forthe ambulance transports. The Plan denied your request. The Plan says that you are responsible for your copays.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 $350 copay for per one-way trip for Medicare-covered ground ambulance services. You have been asked to pay a $350 copay and a $342.28 for the ambulance transports. The ambulance transports fall within the one-way trip for Medicare-covered ground ambulance services benefit category. This means that you have been asked to pay the correct amount and 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 copays forthe ambulance transports provided on December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Urolift procedure (52441).You asked the Plan to pre-approve a Urolift. You say that this is medically necessary.The Plan denied your request. The Plan says the submitted documentation is insufficient to demonstrate medical necessity.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 a Urolift. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an appropriate candidate for Urolift must have moderate to severe BPH defined as an American Urological Association (AUA) symptom score above 7 including signs of obstruction, such as increased voiding symptoms or decreased peak urinary flow rate. The documentation does not show that the enrollee meets these criteria.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 Urolift have not been met.Therefore, we decided that the Plan does not have to pre-approve a Urolift procedure (52441).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the BiPAP device.
You asked the Plan to pre-approve continued use of the BiPAP device. You say that you need the BiPAP
device. The Plan denied your request. The Plan says the documentation did not show you are compliant, you
had positive benefits from using the BiPAP device, or that your symptoms improved.
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 looked at the file and Medicare rules. The record shows you used the BiPAP more than 4 hours 0% of the
time. Based on this information, we decided that Medicare rules for coverage of continued use of the BiPAP
have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of the
BiPAP device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 11, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you never spoke to the doctor. You say that this was supposed to be an individual appointment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $35 copayment for each specialist visit, including outpatient clinic visits. You have been asked to pay a $35 copayment for a specialist office visit. The specialist office visit falls within the "Outpatient hospital services" benefit category. The medical record shows a consultation with this provider during your hospital stay.
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 specialist office visit provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee may benefit from multiple therapies such as physical and occupational
therapy but the documentation does not support that the patient's functional status requires an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for antigen therapy services (95165) provided
on February 24, 2020.
You asked the Plan to waive the copayment for the antigen therapy services. You say that you would like
reconsideration because you were told there would not be a copayment for these services. The Plan denied your
request. The Plan says there is a $20 copayment per visit to a specialist.
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
copayment for specialist services.
You have been asked to pay a $20 copayment for the antigen therapy services. The antigen therapy falls within
the specialist services 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 antigen
therapy services (95165) provided on February 24, 2020.
Your complaint about being given incorrect information regarding your copayment for these services is not a
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (95810).
You asked the Plan to pre-approve the polysomnography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record does not show that the member has the indicated symptoms.
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 polysomnography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical documentation does not include sleep-related problems or symptoms, such as excessive daytime sleepiness, snoring, or observed apneas. There is no BMI, detailed examination of the upper airway, or neck circumference.
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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (95810).