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

We decided that the Plan does not have to pre-approve Entresto Tablet.

You asked the Plan to pre-approve Entresto Tablet. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 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 pre-approve Entresto Tablet. 

Benefits for Entresto Tablet 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound evaluation of abdominal aorta to detect bulging (aneurysm) (76706) performed September 10, 2020.You asked the Plan to waive the copayment forthe abdominal aorta ultrasound. You say that the procedure should be covered due to your medical history.The Plan denied your request. The Plan says Medicare only covers a screeningultrasound for people at risk once per lifetime and that you have already reached your one-time limit. The Plan reprocessed your claim as an outpatient diagnostic test with a $15 copayment.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 there is a once per lifetime limit on Abdominal aortic aneurysm screening. In addition, the contract states that you must pay a $15 copayment for outpatient diagnostic tests and therapeutic services and supplies. The record reflects that you received an abdominal aorta ultrasound on December 29, 2015. This claim fulfills youronce per lifetime limit on the service rendered. In addition, you have been asked to pay a $15 copayment for the abdominal aorta ultrasound. The Plan has chosen to process the claim for the abdominal aorta ultrasound underthe outpatient diagnostic tests and therapeutic services and supplies 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 forthe ultrasound evaluation of abdominal aorta to detect bulging (aneurysm) (76706) performed September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 10, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with thePlan 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. While the enrollee may benefit and participate in multiple therapies the enrollee's functional level does not require this therapy or appear to be able to tolerate this therapy on an intensive rehabilitation therapy program provided in an IRF. Therapy notes indicate enrollee is limited by pain and weakness.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve personal care attendant services. 

You asked the Plan to pre-approve personal care attendant services. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that HHA services may be covered ifit is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 personal care attendant services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee with the combination of age and disability (blindness) would benefit greatly from an overall health standpoint and avoid hospitalizations and avoid placement in a skilled nursing facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care attendant services have been met.Therefore, we decided that the Plan has to pre-approve personal care attendant services.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services for a routine venipuncture provided on 
September 4, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you were sent to this laboratory by your 
physician who ordered the routine venipuncture. The Plan denied your request. The Plan says you did not use 
an in-network provider or have an approved prior authorization to see this out-of-network provider. 
 
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 
laboratory 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 laboratory services for a routine venipuncture provided on 
September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network (OON) provider.

You asked the Plan to pay for office visits. You say that this should be covered with a co payment.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 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 medical services provided by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional home physical therapy visits and home skilled nursing visits.You asked the Plan to pre-approvethe additional home physical therapy and home skilled nursing visits. You say that the records provided support the need for the requested services.The Plan denied your request. The Plan says the records do not support the need for a skilled physical therapist services or skilled nursing servicesat this time.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 additional home physical therapy and home skilled nursing visits. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support that the enrollee requires skilled therapy or skilled nursing services for the treatment of illness or injury. The enrollee does not have complex wound care or other skilled nursing seed. The enrollee's functional level does not require the ongoing skills of a professional therapist. The enrollee has been instructed on safety and home exercises.
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 additional home physical therapy and home skilled nursing visits have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional home physical therapy visits and home skilled nursing visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician visit. You say that your provider depends on the facility to verify eligibility and obtain proper authorization.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 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 on February 11, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe computed tomographic angiography (CTA) of the heart (75574).You asked the Plan to pre-approvethe CTA of the heart. You say that this service is medically necessary.The Plan denied your request. The Plan says the criteria for the CTA scan has not been met.The Plan must follow Medicare rules. Medicare rules say thatCT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CTA of the heart. Our reviewer says that the service is not medically necessary and reasonable. Our physician reviewer found the medical records supports the rationale that the service requested does not meet pre-test guidelines and the significanceof the pre-testprobability is not appropriate for this test.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 CTA of the heart have not been met.Therefore, we decided that the Plan does not have to pre-approvethe computed tomographic angiography (CTA) of the heart (75574)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (75574-AT) (CT scan).You asked the Plan to waive the copayment fora CT scan. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the correct copayment was 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 $110 copayment for outpatient diagnostic tests. You have been asked to pay a $110 copayment for a CT scan. The service at issue falls within the outpatient diagnostic tests 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 fora computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (75574-AT) (CT scan).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee did not undergo proper conservative therapy prior to this request and there are no clinical 
findings on the examination to reasonably waive the requirement for conservative care. Benefit plan language 
indicates that there must be documentation of unsuccessful non-surgical medical management. In this case, 
the enrollee has complained of chronic left hip pain.  However, there was no detailed evidence of failure of 
reasonable comprehensive conservative treatment prior to this request. (The provider stated he ?discussed the 
patient?s radiographs, and the natural history of his condition. Treatment options were discussed including 
alternatives to surgery.  Discussed the atypical presentation of his buttock/posterior base pain. Will refer to 
primary care sports medicine for diagnostic USG IA injection to determine if symptoms are due to intra-
articular pathology.)  Therefore, given the absence of documented evidence of a failure of specific 
conservative treatment, the requested left hip arthroplasty 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hip surgery for the enrollee.
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 service is medically necessary. The Plan denied 
your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 
level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health care, or in 
a long-term care 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 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 patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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. Specifically, the care the patient needs can be met 
at a lower level of care. This means the service requested in not medically reasonable or necessary. Therefore, 
we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services.
Appeal type: SNF
Decision: Favorable

We decided that the Planhasto pay forskilled nursing services (HCPCS G0493) provided to the enrollee on February 12, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthatclaims are required to be billed on the Original Medicare form which is CMS-1450, also known as the UB-04.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT CodeManual definition of HCPCS code G0493 is "Skilled services of a registered nurse (rn) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting."We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found the documentation in the case file supports the skilled services of a registered nurse for the observation and assessment of the patient's condition, each 15 minutes.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 services have been met.Therefore, we decided that the Planhas to pay forskilled nursing services (HCPCS G0493) provided to the enrollee on February 12, 2020.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crutch substitute (E0118).You asked the Plan to pre-approvea crutch substitute (E0118). You say that because of an injury you need a knee scooterto assist you.The Plan denied your request. The Plan says knee scooters are not a covered item.The Plan must follow Medicare rules. The rules say that when there is no published policy for an item, contractors may make individual determinations when reviewing claims.Crutch substitute is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvea crutch substitute (E0118).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve Farxiga. The Plan denied your request. The Plan says this drug is not 
covered under the Part B 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 pre-approve Farxiga.  
 
Benefits for Farxiga 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that your doctor says you need this service.The Plan denied your request. The Plan says you do not meet the requirements for approval of the requested service.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that you are not within the required age range of 55-77 years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening