Persius/hicric huggingface dataset:
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 enrollee's condition has stabilized and he is ready for discharge from the acute care hospital. You say that LTACH services are needed in order for the enrollee to regain maximum/prior level of functioning and in order to continue a multi-disciplinary approach to care. The Plan denied your request. The Plan says LTACH services are not medically necessary because the records show that the enrollee does not have a stable and secure airway or permanent feeding tube.
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 although ongoing acute care appears to be needed for the enrollee, he does not require services at the LTACH that are not already available at the current acute care hospital setting. Tracheostomy is still needed to stabilize the enrollee, and there was no indication the enrollee would need more than 25 days of acute care moving forward to warrant transfer to LTACH at this time. Ongoing care at the current facility is most appropriate. 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: Lab
Decision: Favorable

We decided that the Plan has to pay for Guardant360 testing provided on October 3, 2019.
You asked the Plan to pay for Guardant360 testing. You say that this testing was deemed medically necessary
by the treating physician and the enrollee did not have an in-network option. The Plan denied your request. The
Plan says that the denial of payment for this service is correct, because this test was not covered by Medicare
for this date of service.
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 was in-network or out-of-
network with the Plan. The documentation submitted does not include prior notice that this testing would not
be covered. Without this information, we cannot determine whether the lab order made constituted plan directed
care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for Guardant360 testing
provided on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 5, 2019. You asked the Plan to pay for the laboratory services. You say that your doctor asked you to have these services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 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 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 provided on July 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the heart (75571).You asked the Plan to pre-approvea CT scan of the heart. You say that the service is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.ThePlan follows Medicare rules. Medicare rules say that CCTA can reliably rule out the presence of significant coronary artery disease (CAD) in patients with a low to intermediate probability of having CAD and can reliably achieve a high degree of diagnosticaccuracy and technical performance necessary to replace conventional angiography.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 CT scan of the heart. Our reviewer says that the service is not medically necessary. Our physician reviewer found CT coronary scoring is not a covered benefit per plan guidelines. The enrollee has well controlled lipid profile and is asymptomatic with no history of chest pain, arrhythmia or other cardiac symptoms.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 CT scan of the heart have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the heart (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, (root canal) (D3330) provided February 11, 2020.
You asked the Plan to pay for the root canal. You say that no one goes in for an elective root canal. You are trying to save your teeth and this root canal is because your tooth is cracked. You are entitled to this root canal according to coverage. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 pay for endodontic therapy, (root canal) (D3330) provided February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia anxiolysis (D9230) provided on February 19, 2020.
You asked the Plan to pay for the dental services. You say that this should be paid because you have been paying $20 for years without using the dental plan so this should be taken care of. The Plan denied your request. The Plan says the service is not a covered benefit under 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, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia anxiolysis (D9230) provided on February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 15, 2020 to January 17, 2020.You asked the Plan to pay for the self-administered drug. You say that the Plan should pay this claim The Plan denied your request. The Plan says the self-administered drugs are not covered by your 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 drug at issuehere is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided from January 15, 2020 to January 17, 2020.Benefits for the self-administered drug 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: Unfavorable

We decided that the Plan does not have to pay for the provision of test materials and equipment for home INR monitoring provided on January 20, 2020.You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says Medicare allows code G0249 no more than once every 4 weeks.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 G0249 is provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria. We find that CPT code G0249 was previously billed and paid for by the Plan for services provided on January 7, 2020. The rules say that Code G0249 is billable every 25 days. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the provision of test materials and equipment for home INR monitoring provided on January 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says you are no longer aggressive and you are taking your medication.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 andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment facility beyond the June 26, 2020. You can be treated in a lesser restrictive setting, as you were not showing any suicidal or homicidal ideation, auditory, or visual hallucinations. You were not showing any behaviors or aggression, and you were being cooperative and compliant, while not showing any acute threats to 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient mental health facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide the disposable sensors.
You asked the Plan to provide the disposable sensors (A9276). You say that you were told your CGM and supplies would be covered. The Plan denied your request. The Plan says since the CGM is not one of the approved continuous glucose monitors the supplies for it are not approved either.
The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor. In this case, the CPT Code Manual definition of code A9276 is Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system. You asked the Plan to provide sensors for an interstitial continuous glucose monitoring system. We find that CPT code A9276 is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of disposable sensors have not been met. Therefore, we decided that the Plan does not have to provide the disposable sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 7, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has 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
physician's 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 physician's services provided on February 7, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the retrobulbar injection provided on December 18, 2019.You asked the Plan to pay for the retrobulbar injection. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that codes for ophthalmic injections shall not be reported separately with other ophthalmic procedures codes when the injected substance is an anesthetic.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.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay forthe retrobulbar injection provided on December 18, 2019.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus (J7507). You asked the Plan to pre-approve a tier exception for Tacrolimus. You say that the exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions. The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. You can find this rule in 42 CFR 423.4. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Tacrolimus have not been met. Specifically, the requested drug is covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs are not subject to tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Tacrolimus (J7507).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lynparza 150mg tablets for the enrollee.
You asked the Plan to pre-approve the tablets. You say that this is medically necessary. The Plan denied your
request. The Plan says this medication was denied as it is not a Part B drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lynparza 150mg tablets for
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omega-3 Fish Cap 1000mg 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 medication is covered under Part D, which the enrollee does not have benefits for.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Omega-3 Fish Cap 1000mg
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH. 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 review has determined that the enrollee require services at the LTACH that are not available at the acute care hospital where she 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia provided on November 18, 2019. You asked the Plan to waive the coinsurance for anesthesia. You say that you were informed services would be covered by insurance. You say that you didn't understand that the services could be considered out-of-network. The Plan denied your request. The Plan says the coinsurance applied correctly. 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% of the Medicare-allowed amount for outpatient surgery services at an out-of-network outpatient hospital facility. You have been asked to pay $30.99, which is 50% of the allowed amount for anesthesia. The allowed amount is $61.99 (50% x $61.99 = $30.99). Anesthesia falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 coinsurance for anesthesia provided on November 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided on February 26, 2020.You asked the Plan to waive the copayment forwound debridement. You say that you did not receive an outpatient surgical procedure and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received wound debridement on February 26, 2020. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 forwound debridement provided on February 26, 2020.