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

We decided that the Plan does not have to pay for the transitional care management services (99495) rendered by the out-of-network (OON) provider on February 22, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 transitional care management services (99495) rendered by the out-of-network (OON) provider on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical supplies provided on April 6, 2021.
You asked the Plan to pay for the Betadine or iodine swabs/wipes, per box (A4247). You say that the enrollee needs these supplies. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Wipes are non-reusable disposable supplies not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the medical supplies provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (E0218).

You asked the Plan to pre-approve a cold pad with pump. You say that you require the cold pad with pump, that it will help with your pain. The Plan denied your request. The Plan says it is not a Medicare covered item.

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is not a covered item. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (E0218).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a history of kidney cancer. A study on December 29, 2020 showed stable kidney changes. The guidelines support a follow-up computed tomography (CT) scan of MRI of the abdomen one to six months after ablation of cancer and then annually for five years. The requested MRI is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on February 16, 2021.
You asked the Plan to pay for the hearing aids. You say that the new hearing aids are an upgrade and the cost is less than what is allowed. You say that the plan should be interested in saving money for the members and you are submitting the claim for reimbursement. The Plan denied your request. The Plan says this hearing aid vendor is a non-participating provider and your Plan does not have out-of-network hearing benefits.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from a network provider. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on February 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray, 2 views (71046), the set up for portable x-ray equipment (Q0092), and the transport of a portable x-ray (R0070) provided on March 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the imaging services. You say that the provider requesting this service is in network. You also say that this should be covered. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee.
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 imaging services. We found no exception that would require the Plan to pay for these imaging services. Therefore, we decided that the Plan does not have to pay for the chest x-ray, 2 views (71046), the set up for portable x-ray equipment (Q0092), and the transport of a portable x-ray (R0070) provided on March 16, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart.

You asked the Plan to pre-approve the scan. 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 CT 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found CT scan of the heart with quantitative evaluation of coronary calcium can be considered in intermediate-risk or selected borderline-risk adults, if the decision about using statin therapy is uncertain. In this case, you are already on statin therapy. The requested scan is not medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prolonged evaluation and management service before
and/or after direct patient care (CPT code(s): 99358 and 99359) provided to the enrollee on March 16, 2021, by
an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider, and the services were not urgent or emergent, nor were they approved in advance.
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
prolonged evaluation and management service before and/or after direct patient care (CPT code(s): 99358 and
99359) provided to the enrollee on March 16, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH level of care is needed for this enrollee and will provide the best chance for them to progress with continued respiratory support and aggressive weaning. The Plan denied your request. The Plan says the requested service is not medically necessary.
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. Our reviewer found that the enrollee does not 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 Plan.
Our physician reviewer also found that 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the adjustable bed purchased on May 4, 2021.
You asked the Plan to reimburse for the adjustable bed. You say that the doctor prescribed the adjustable bed on April 22, 2021. You state you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says this is not covered by the health plan or Medicare.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adjustable bed have not been met. Medicare will not cover equipment that is primarily and customarily used for nonmedical purposes or equipment used for a patient's comfort or convenience. Medicare rules also state that in order to be reimbursed by the health plan or Medicare for services provided to enrollees, the provider of services must be Medicare-certified, contracted with the health plan, and licensed by the State. Providers who do not meet these requirements are not eligible to receive payment for services rendered to enrollees. An adjustable bed is not primarily or customarily used for medical purposes, and the place you purchased the bed from does not meet Medicare's requirements to receive payment. Therefore, we decided that the Plan does not have to reimburse for the adjustable bed purchased on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 27, 2020.
You asked the Plan to pay for lab testing. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of payment for this testing is correct, because this testing was performed for
screening purposes which is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service billed on this claim. Without this information, we cannot determine
whether this lab testing was ordered for Medicare-covered purposes. Based on this information, we decided
that Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory testing provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep test.
You asked the Plan to pre-approve home sleep test (hst) with type iii portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ecg/heart rate and 1 oxygen saturation (G0399). You say that the enrollee needs a home sleep study to check how the CPAP is working. The Plan denied your request. The Plan says the enrollee was already diagnosed with obstructive sleep apnea.
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 home sleep test (hst) with type iii portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ecg/heart rate and 1 oxygen saturation (G0399). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee complains about having a dry nose. There is no evidence that the member failed to improve despite adding a humidifier to his CPAP machine. In addition, a home sleep study is intended to be used for the diagnosis of obstructive sleep apnea (OSA) and this member was diagnosed in 2017. The enrollee is compliant with his CPAP treatment and clinical features of OSA have not recurred. The requested home sleep test is 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 home sleep test (G0399) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep test.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 13, 2021.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on February 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 2, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the clinical documentation is clear and demonstrates medical necessity. The Plan denied your request. The Plan says you did not request prior authorization as required.

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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 2, 2021 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computerized tomography (CT) scan and Magnetic resonance imaging (MRI) scan.
You asked the Plan to pre-approve CT and MRI scans. You say that you were unable to hold anything with weight or lift your arm. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Medicare rules say that MRIs 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 CT and MRI scans. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have left upper arm pain. The documentation indicates that you had a remote history of left shoulder injury. You were assessed with arm weakness and x-rays of the left humerus and shoulder were ordered, along with a left shoulder CT. The shoulder x-ray found osteoarthritic changes of the left acromioclavicular joint and compression defects in the left humeral head consistent with Hill-Sachs deformity. This was found to correlate clinically with the prior history of glenohumeral dislocation. The
humerus x-ray found no significant radiographic abnormalities. Regarding the CT scan, there has been no indication that you have undergone a six-week trial of doctor prescribed treatment that has failed to resolve your issues or that you have sustained an injury resulting in a Rotator cuff tear. Further, there is no indication that this imaging has been requested for the purposes of planning a future surgery. Regarding the shoulder MRI, there is no indication in the records that the x-rays performed failed to provide the provider with all of the details needed to perform treatment. In addition, there is no indication that you have undergone a recent six-week trial of doctor-prescribed treatment that failed to resolve the complaints. Therefore, you do not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT and MRI scans have not been met. Therefore, we decided that the Plan does not have to pre-approve computerized tomography (CT) scan and Magnetic resonance imaging (MRI) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 5, 6, 7, 8, 10, 11, and a pontic (D6240) for tooth # 9.
You asked the Plan to pre-approve the fixed bridge. You say that you need these services urgently. You say that you are not able to eat. You say that you are a Korean war veteran. You also say that you do not want to make a very large payment for this service. The Plan denied your request. The Plan says fixed prosthodontics are not covered.
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 fixed bridge is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 5, 6, 7, 8, 10, 11, and a pontic (D6240) for tooth # 9.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zepzelca 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 that this drug is not being prescribed for a supported medically accepted indication.
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 medically reasonable and necessary. Our physician reviewer found Zepzelca is FDA
approved for the treatment of metastatic small-cell lung cancer in adults with disease progression on or after
platinum-based chemotherapy. Small cell cancer of the prostate is treated the same as small cell lung cancer.
The enrollee has progressed on prior platinum therapy. The service is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve
Zepzelca for the enrollee.
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.