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

We decided that the Plan has to pay for laboratory testing provided on May 31, 2019.
You asked the Plan to pay for lab tests. You say that the ordering physician's medical records are kept by the physician in their office and never supplied to you, and you only receive information necessary to complete the lab tests ordered. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because medical records were not obtained from the ordering physician to determine the clinical utility of this testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan, nor did the Plan submit documentation of prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that its decision to deny payment for this claim is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on May 31, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885) for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the information submitted does not meet the plan's step therapy criteria guidelines for coverage.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drug -Retacrit. There is no indication that Retacrit would likely be less effective and/or likely have adverse effects.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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for surgery
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The
Plan denied your request. The Plan says the supplied clinical information does not indicate the presence or
performance of an inpatient-only procedure or expectations of severe perioperative acute complications.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the review has determined that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital care (including
earlier ED and/or observation care) would span two midnights. The enrollee appears to have controlled comorbidities
that would classify him as an American Society of Anesthesiology (ASA) class 3. The supplied
clinical does not indicate the presence of performance of an IPO procedure or expectations for severe
perioperative acute complications.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient admission for surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0428, A0425) provided January 3, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $350 copayment for ambulance services. You have been asked to pay a $350 copayment for the ambulance transport. The ambulance transport falls within the ambulance 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 an ambulance transport (A0428, A0425) provided January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0272) provided on January 16, 2020.
You asked the Plan to pay for the bitewings. You say that you were never told that you would be responsible
for paying for the x-rays you had. You also say that you were under the impression that your appointment
would be fully covered. The Plan denied your request. The Plan says this service is not covered by the Plan.
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, bitewings (D0272) are not among
those covered under this benefit. The contract clearly states that complete series of intraoral x-rays (D0210) and
panoramic x-rays (D0330) are the only x-rays that are covered by the Plan. Therefore, we decided that the Plan
does not have to pay for the bitewings (D0272) provided on January 16, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a magnetic resonance imaging (MRI) of the lumbar spine (72148)
provided on September 26, 2019 by the appealing provider.
You asked the Plan to pay for the MRI of the lumbar spine. You say that the service was provided and payment
should be rendered. The Plan denied your request. The Plan says that there is no allowable reimbursement rate
for the code billed. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
code 72148 is an MRI of the lumbar spine.
We find that CPT code 72148 is supported in the medical record. Specifically, the procedure is being billed on
an outpatient hospital form. There is an Outpatient Prospective Payment system (OPPS) rate for this service
when it is provided by a hospital. Based on this information, we decided that Medicare rules for coverage of the
MRI of the lumbar spine have been met. Therefore, we decided that the Plan has to pay for a magnetic
resonance imaging (MRI) of the lumbar spine (72148) provided on September 26, 2019 by the appealing
provider.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on July 1, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on July 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on review of the available records, the enrollee does not meet criteria for SNF admission. The enrollee was medically stable with no evidence of need for rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy but does not require a program with daily therapies. SNF admission is not medically necessary based on the enrollee's current functional status and lack of nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar medial branch/facet blocks.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no indication that physical therapy cannot be done.
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 blocks. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no documentation of physical therapy, a home exercise program, or a trial of NSAIDs
documented. There are radicular symptoms. The request does not meet the LCD criteria. The request is
considered not medically 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 blocks have not been met. Therefore, we decided that the Plan does not have
to pre-approve lumbar medial branch/facet blocks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not supported for peripheral T cell lymphoma.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a T-cell lymphoma, requesting coverage for Rituximab. T-cell lymphoma lacks CD20 which is a target of rituximab. Rituximab is not a standard treatment for T-cell lymphomas. The service is 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the criteria for coverage of SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, had routine SP catheter care, and uncomplicated wound care to his lower
extremities and sacrum. The enrollee used oxygen via nasal cannula. The enrollee received physical therapy
and occupational therapy in the acute hospital. The enrollee was able to transfer with a sarastedy and contact
guard assist. The enrollee requires varying assist with activities of daily living. There are no identifiable skilled
nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you need these stockings to help with swelling in your legs, and that you cannot afford them. The Plan denied your request. The Plan says the compression stockings are not covered for lymphedema.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power operated vehicle (K0806).
You asked the Plan to pre-approve a group 2 power operated vehicle. You say that this should be covered. The
Plan denied your request. The Plan says sufficient information was not received to show that this was
medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file does not show that you have a personal mobility deficit that impairs your participation in mobility
related activities of daily living and that you are capable of safely operating the requested device. Without this
information, medical necessity cannot be determined. This means that Medicare rules for coverage of a PMD
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated
vehicle (K0806).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 3, 2019 to October 1, 2019.
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 the services were not billed with the required FIPS code.
The Plan must follow Medicare rules. The rules say that where required by law or regulation, home health claims must be billed with a FIPS code. We looked at the file and Medicare rules. The claims were not billed with the required FIPS code. 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 pay for the home health services rendered from August 3, 2019 to October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an emergency room and office visit
provided on November 17, 2018 to November 19, 2018.
You asked the Plan to waive the copayments for the Emergency Room and office visits. You say that the
copayment should be waived. The Plan denied your request. The Plan says the correct cost share 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 an $80
copayment for Emergency Care and a $30 copayment for office visits.
You have been asked to pay $110 in copayments for an Emergency Room visit and an office visit. 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 copayments for an emergency room and office visit provided on November 17,
2018 to November 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) on tooth #2 provided on December 23, 2019.
You asked the Plan to pay for the crown. You say that the enrollee's amalgam was over 2/3 of intercuspal distance. You also say that the distal marginal ridge had a distal crack/fracture. The Plan denied your request. The Plan says the documentation submitted does not meet the Plan's clinical criteria for a 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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the service was not medically necessary. Our physician reviewer found due to the lack of significant coronal breakdown or evidence of a cracked tooth indicated in the documentation, the criteria for coverage for a crown restoration (D2740) for tooth #2 has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #2 provided on December 23, 2019.