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

We decided that the Plan does not have to pay for surgical assistant services provided on August 22, 2019.
You asked the Plan to pay for surgical assistant services. You say that these services should be covered. The
Plan denied your request. The Plan says these services were not necessary.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. The provider in question is an LSA (licensed surgical assistant). Therefore, we decided that the
Plan does not have to pay for surgical assistant services provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injection (J0897).
You asked the Plan to pre-approve Prolia injection. You say that the authorization for the medication is medically necessary. The Plan denied your request. The Plan says certain criteria must be met for coverage of this drug.
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 Prolia injection. Our reviewer says that this enrollee does not meet the criteria. Our physician reviewer found although Prolia is also a reasonable choice, the plan requires using Reclast before Prolia. This enrollee seems to have had GI side effects from alendronate (po) and hence an iv bisphosphonate would be reasonable to try instead. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injection (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on September 9, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan mustfollow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on September 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency department services (99291, 93010 and 93042) provided on September 19, 2019.You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that the emergency department services are not supported in the record. Specifically, the Primary Diagnosis in this case is R65. R65 is a "Code first" code, which means that the underlying condition should be sequenced first. In this case, the underlying conditions were known but were not sequenced first. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (99291, 93010 and 93042) provided on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve inpatient psychiatric hospitalization for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansayscontinued stay in his hospital would constitute custodial care.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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 20, 2020 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 and no aggressive behaviors.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinpatient psychiatric hospitalization for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon July 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergencysituation, has been documented. 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 Plandid not pre-approve the servicesat 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 physician's services provided on July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology services rendered to the Enrollee on May 8, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the molecular pathology services rendered to the Enrollee on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this doctor has treated you for ten years. The Plan
denied your request. The Plan says there are in-network options that can provide the needed care.
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 provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon August 14, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 servicesat 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 physician's servicesprovided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the Enrollee on July 22, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the Enrollee on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you were having increased heart palpitations and, on the recommendation of a friend, you went to see a doctor. You say that you did not know you should go to the ER or urgent care center.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 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 foran office visit provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure Plus.You asked the Plan to pre-approve Ensure Plus. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that ifa special enteral nutrition formula is provided and if the medical record does not document why that item is medically necessary, it will be denied as not 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 Ensure Plus. Our reviewer says that Ensure Plus is not medically reasonable and necessary. Our physician reviewer found that the enrollee in this caseis being recommended 3 cans of Ensure Plus per day to help with weight loss due to poor appetite associated with a motility disorder. The enrollee is currently eating regular meals as well as similar dietary supplements. There was no indication from the records that there was failure of eating a modified solid food diet to increase calories to help justify this dietary supplement. Therefore, this request for Ensure Plus will be considered not 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 Ensure Plus have not been met.Therefore, we decided that the Plan does not have to pre-approve Ensure Plus.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic mammogram provided on September 5, 2019.You asked the Plan to waive the copayment fora diagnostic mammogram. You say that you disagree with the charges because you were told that you would not owe a copayment.The Plan denied yourrequest. 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 $100 copayment for each radiological diagnostic service. The medical records show that you received a diagnostic mammogram on September 5, 2019. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked topay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora diagnostic mammogram provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the easy rest support chair provided from October 7, 2019 through October 14, 2019 by an out-of-network provider.
You asked the Plan to pay for the DME. You say that you were told the chair was covered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the easy rest support chair provided from October 7, 2019 through October 14, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on September 17, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you were not informed anything would be at your expense. You say that you did not authorize the provider to perform anything that would cost you money.The Plan denied your request. The Plan says the copayment 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 $10 for Medicare-covered laboratory tests. You have been asked to pay a $10 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services provided on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services (71045, R0075, and Q0092) provided on July 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for imaging services. You say that these services should be paid. The Plan denied your request. The Plan says these 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the imaging services (71045, R0075, and Q0092) provided on July 18, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveRituxan injections.You asked the Planto pre-approvethe Rituxan treatments. You say that this medication is shown to be beneficial in managing this enrollee's condition and should be continued.The Plandenied your request. The Plansaysevidence-based guidelines do not support this use of the medication for this condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Rituxan treatments. Our reviewer says that the requested treatment is not considered medically reasonable and necessary. Our physician reviewer found the enrollee has been prescribed this medication for chronic idiopathic demyelinating polyneuritis (CIDP). He had previously been treated with IVIG but this was stopped secondary to renal impairment. Rituximab is not currently FDA approved for use in CIDP nor is it readily supported for use in the Compendia for CIDP. The only published evidence on the use of this drug in CIDP is limited to case reports and retrospective case series. There have been no prospective studies completed to date of rituximab in CIDP which permit conclusions to readily support the use of this drug in the specified diagnosis. In as much it cannot be said to be reasonable and 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 the Rituxan treatments have not been met.Therefore, we decided that the Plandoes not haveto pre-approveRituxan injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member needs inpatient rehab to be
rehabilitated back to baseline functioning. The Plan denied your request. The Plan says that the members needs
can be met at home with therapy services, with home health care visits, or in a doctor's office.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplex proton therapy.You asked the Plan to pre-approveproton therapy. You say that proton beam therapy is medically necessary and the superior treatment for the enrollee's prostate cancer.The Plan denied your request. The Plan says there is no definitive data to suggest that proton therapy is superior to IMRT for prostate cancer treatment.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 proton therapy. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. To date, there are no compelling data tosuggest that proton therapy is superior to or more beneficial than IMRT/IGRT. Notably, registry studies are not clinical trials or studies, and have a much less rigorous development process. A tumor registry does not address a specific scientific questionbut rather registers the patient's clinical and treatment information into a database for potential analysis in the future. Therefore, the requested services are not medically reasonable and 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 proton therapy have not been met. Therefore, we decided that the Plan does not have to pre-approvecomplex proton therapy.