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

We decided that the Plan does not have to pre-approve 48 additional routine transportation trips.

You asked the Plan to pre-approve the 48 additional routine transportation trips. You say that you are unable to drive due to a medical condition. You say that you need transportation to get to your doctors' appointments. The Plan denied your request. The Plan says the enrollee has met the Plan limits, which have been set in the subscriber agreement.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way routine transportation trips per year.

We looked at your request, the records in the case file, and the rules. The records show that, at the time of your request, you had received coverage for 47 one-way routine transportation trips in the 2021 calendar year. This means that, at the time of your request, you had 1 routine transportation trip remaining of your 2021 routine transportation benefit. Based on this information, we decided that the number of routine transportation trips being requested would exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 48 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair.

You asked the Plan to pre-approve the Group 3 Power Wheelchair. You say that you would like reconsideration because the requested Group 3 Power Wheelchair is medically needed. The Plan denied your request. The Plan says the member does not have a medical diagnosis of neurological disease, mypoathy or congenital skeletal deformity.

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; or 

3. 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-approve a Group 3 Power Wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that despite multiple medication changes, the enrollee continues to have random bouts of hypoglycemia. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic continuous glucose monitor.

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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive audiometry evaluation (92557) tympanometry & reflex threshold measurements (92550) provided on March 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the professional services. You say that your hearing loss prevents you from hearing conversations and television and you required hearing aids. You were unable to hear and got a professional evaluation and the plan should pay for the services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 comprehensive audiometry evaluation (92557) tympanometry & reflex threshold measurements (92550) provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit you had on October 19, 2020.

You asked the Plan to waive the copayment. You say that you should have been able to see your PCP. The Plan denied your request. The Plan says you are responsible for the 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 you must pay a $25 copayment for specialist services. 

Review of the file shows that you had a specialist visit on October 18, 2020. You have been asked to pay a $25 copayment for the services. The visit falls within the physician 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 the specialist visit you had on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by a provider who is not in your primary network.

You asked the Plan to pre-approve an office visit. You say that you want to see this provider to avoid radiation therapy. The Plan denied your request. The Plan says the requested service is available in your primary network. The Plan has also indicated that they have approved this service with a provider in your primary network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a primary network provider with the Plan. The Plan has providers in your primary network available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by a provider who is not in your primary network.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from August 26, 2021, forward.

You asked the Plan to pre-approve continued inpatient psychiatric care. You say that this requested care continues to be medically necessary. The Plan denied your request. The Plan says the enrollee's condition has improved and is no longer a threat to others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically necessary and reasonable. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 26, 2021 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from August 26, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenomics panel (81225, 81226, 81227, 81230, 81231, 81291, 81402, 81479) provided on February 8, 2021.

You asked the Plan to pay for a pharmacogenomics panel. 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. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel.

We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81291, 81402, and 81479 are not supported in the medical record. Specifically, these codes were used to report tests performed as a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a pharmacogenomics panel have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenomics panel (81225, 81226, 81227, 81230, 81231, 81291, 81402, 81479) provided on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says the current acute care hospital can provide acute care services until the member's condition allows transfer to an alternate level of care, such as skilled nursing facility, acute inpatient rehabilitation, home health care, nursing home, or home.

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 that the enrollee is a 73-year-old female who was admitted to the current acute care hospital with severe abdominal pain and altered mental status later found to be an abscess and sepsis. She was treated with resection, percutaneous drain, TPN. Recent notes state that the enrollee is not improving significantly, and the treating physicians stated that she has a poor prognosis. The enrollee appears to not be expected to improve and hospice care was offered. In the meantime, only short-term acute care services are expected and can safely be received in the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time as there appears to be no advantage. Transfer to a lower level of care may be considered when treatment has been completed. 

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 LTACH services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99281) provided March 26, 2021.

You asked the Plan to waive the copayment for the emergency visit. You say that you received a bill for $50 for emergency room services but you did not go to the hospital you went to urgent care. You do not have the money to pay for it. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $50 copay for each Medicare covered emergency room. 

You have been asked to pay $50 copay for the emergency visit. The emergency 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 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 emergency department visit (99281) provided March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.

You asked the Plan to pre-approve the referral. You say that you were referred to this provider for alternative health options. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 19, 2020.

You asked the Plan to pay for the services. The Plan denied 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 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 for the services provided by an out-of-network provider on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OON provider.

You asked the Plan to pre-approve the consultation. You say that you were told you needed the services rendered by an oral surgeon. You also say that you are in pain and would like this issue resolved. The Plan denied your request. The Plan says your request to use an OON oral surgeon is upheld because there are in-network providers available in your area.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve OON provider.
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 records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute and/or critical care. The Plan says that the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.

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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins when required (D2950) for tooth #27.

You asked the Plan to pre-approve the core buildup. You say that a root canal, core buildup, and crown are recommended for tooth #27 to optimize chewing function. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that the enrollee had this service less than 60 months ago.

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 enrollee is limited to 1 crown per tooth, every 5 years. The record shows that the enrollee received a core buildup on tooth #27 on April 19, 2019 and the enrollee's crown benefit for tooth #27 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins when required (D2950) for tooth #27.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says you have not tried and failed the preferred drugs, Orthovisc and Monovisc.

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 Synvisc-One. Our reviewer says that Synvisc-One is not medically necessary. Our physician reviewer found you have not trialed viscosupplemental treatments such as Orthovisc and Monovisc. The reviewer found that step therapy, as outlined by the Plan, requires that these be trialed first. The reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Therefore, the reviewer found that without the support of the documentation, Synvisc-One cannot be approved, as step criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Specifically, the record shows that you have not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap issue, and there are in-network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.