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

We decided that the Plan has to pre-approve spinal surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the submitted documentation does not show a trial of other treatments covered by the health plan.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with chronic severe neck pain radiating to the left shoulder with signs/symptoms of progressive cervical myelopathy. There is imaging evidence of multilevel cervical spondylosis at C3/4, C4/5, and C5/6 with severe central canal stenosis (6 mm) and cord flattening. Additionally, there is radiographic evidence of a cervical kyphotic deformity with anterolisthesis at the C3/4 and plausible subtle instability on x-ray. He has failed to improve with reasonable conservative treatment, including activity modification and medications. The neurosurgeon has opined the contraindication for physical medicine therapy or injections. Under consideration is a request for anterior-posterior cervical decompression and fusion surgery. Current evidence based medical literature would support this request for surgical intervention in the setting of multilevel cervical spondylotic myelopathy. Therefore, this request for spinal surgery is 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve spinal surgery 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by a non-network provider.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 rendered by a non-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 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 medical services provided on January 15, 2020 by a non-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brilinta.
You asked the Plan to pre-approve Brilinta. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 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 Brilinta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan coded 93925 provided on February 25, 2020.You asked the Plan to pay for the duplex scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 93925 is duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study.We find that CPT code 93925 is not supported in the medical record. Specifically, this code was billed with modifiers LT and RT. Modifiers RT and LT are not allowed for this code when it is a bilateral study. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met.Therefore, we decided that the Plan does not have to pay for the duplex scan coded 93925 provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 an outpatient visit provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 27, 2019 by a non-network provider.
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 rendered by a non-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 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 medical services provided on December 27, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from May 6, 2019 to May 11, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should like your $750 back because you were never in the hospital on May 8, 2019. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment for each day for days 1 to 5 for inpatient hospital care. You have been asked to pay a $250 copayment for each day of the inpatient hospital stay. ($250 x 3 = $750). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows that you were in admitted in the hospital from May 8, 2019 to May 11, 2019.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from May 6, 2019 to May 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept surgical spine procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is always considered investigational.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept Procedure is experimental for the treatment of degenerative back pain. More research is needed to show the safety and efficacy of the procedure. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept surgical spine procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 9, 2020 by a non-participating provider.
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 rendered by a non-participating 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 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 medical services provided on March 9, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammography and laboratory services provided on March 4, 2020.You asked the Plan to pay for the mammography and laboratory 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 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 a mammography and laboratory services provided on March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" beyond the last covered date. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.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 care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 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 forthe medical services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 1, 2019 to September 13, 2019 by a non-network provider.
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 rendered by a non-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 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 medical services provided on April 1, 2019 to September 13, 2019 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided November 9, 2019 to November 12, 2019.You asked the Plan to pay for post-stabilization inpatient hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says there were in-network facilities available to provide the post-stabilization hospital care. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization inpatient hospital care. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. The enrollee was stable for transfer to a plan facility after the initial emergency room care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided November 9, 2019 to November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of impacted tooth - partially bony tooth.
You asked the Plan to pre-approve this service. You say that you need to have this tooth removed so you can get dentures. The Plan denied your request. The Plan says that this is not covered under your benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of impacted tooth - partially bony tooth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device and appliance (E0652 and E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and appliance (E0652 and E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON physical therapy services. You say that this should be covered as in-network. The Plan denied your request. The Plan says there are in-network providers available 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 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 physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Durolane viscosupplement injections.
You asked the Plan to pre-approve the Durolane injections. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says there is no reason documented that the plan's preferred drugs could not be used.
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 Durolane injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on the plan's step therapy rules. Our physician reviewer found the enrollee is a 91 year old male with osteoarthritis of the knee. He has failed conservative treatment and Durolane injections have been requested. Based on the medical records provided, the patient has not tried and failed the required drug, Orthovisc or Monovisc. There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient.
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 Durolane injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Durolane viscosupplement injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve glucose monitor test strips.
You asked the Plan to pre-approve glucose monitor test strips. You say that because of a medical condition you need to monitor your sugar levels. The Plan denied your request. The Plan says you are not diabetic and therefore do not meet criteria for test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. You do not have an applicable diagnosis. Based on this information, we decided that Medicare rules for coverage of glucose monitor test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve glucose monitor test strips.