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

We decided that the Plan does not have to pay for the chiropractic services (CPT 99070) provided to the
enrollee on October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the chiropractic services (CPT 99070) provided to the enrollee on October 7,
2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on October 29, 2019.
You asked the Plan to pay for the eye refraction. You say that the eye exam included various tests to determine the cause of your eye pain and you believe this test was part of the protocol required to access the pain and eye issues. The Plan denied your request. The Plan says you have exceeded the number of refractions for the 2019 calendar year.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and Medicare's rules. The file shows that the eye refraction was provided in connection to diagnosis and treatment of an illness. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 10, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services 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 these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 10, 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 radiation therapy provider for the enrollee.
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 available from network providers. 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 radiation therapy provider for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for bathing.
You asked the Plan to pre-approve home health aide services for bathing. You say that the enrollee needs this
care. The Plan denied your request. The Plan says the requested services do not meet Medicare criteria for
covered home health services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy. The rules also say that custodial care, such as
help in walking, getting in and out of bed, bathing, dressing, feeding, or using the toilet, is not covered.
We looked at the file and Medicare rules. The record shows that the requested home health services are for
bathing, which is considered custodial care and is not covered. Based on this information, we decided that
Medicare rules for coverage of home health aide services for bathing have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health aide services for bathing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 30, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC. 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 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 medical services provided to the enrollee by an out-of-network provider on August 30, 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 pulmonologist for the enrollee. 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 available from network providers. 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 pulmonologist for the enrollee.
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that while the enrollee is chronically ill with several acute problems, his needs are being met with the current level of care. Therefore, transfer to the LTACH is not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on September 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the services provided to you on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on May 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on May 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.
You asked the Plan to pre-approve continued inpatient mental health care. You say that the enrollee is unsafe for discharge. The Plan denied your request. The Plan says the enrollee no longer needs inpatient 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 continued inpatient mental health care. Our reviewer says that the requested inpatient care is not medically necessary at this time. Our physician reviewer found based on the records provided, it is not expected this enrollee would improve in a reasonable period of time beyond the dates the Plan has approved as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient had no acute events and was not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she does not have dangerousness to self or others and has been compliant with her treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 12, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 medical services provided to the enrollee by an out-of-network provider on October 12, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says this is 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that the enrollee is reported to have neck pain related to a motor vehicle accident. However, according to records provided for review from the enrollee's health plan, the enrollee had a MRI of the cervical spine completed in December 2019. The results of that neuroimaging study were not provided for review, nor were there any updated medical records provided for review which indicated why a repeat study is necessary. Given that there was no new or novel clinical information provided since the time at which the prior imaging study was completed, it cannot be said that a repeat study would be reasonable and necessary. Rather, to the contrary, a second imaging study would otherwise duplicate services previously provided. 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 MRI have been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Epoetin Alfa (J0885).
You asked the Plan to pre-approve Epoetin Alfa. You say that the requested medication is necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
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 Epoetin Alfa. Our reviewer says that the medication is medically necessary. Our physician reviewer found the review has determined that the documentation does support that the Epoetin Alfa is medically reasonable and necessary and safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epoetin Alfa have been met. Therefore, we decided that the Plan has to pre-approve Epoetin Alfa (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are no extenuating circumstances related to geographic access, reasonable continuity of care, or unique medically-recognized qualifications of the requested out-of-network provider to justify prior authorization of out-of-network benefits beyond the transition of care allowance.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 the medical services to beprovided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 22, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
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 denied CPT codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).
You asked the Plan to pre-approve the PWC. You say that you have not received your physical therapy to be
able to use your prosthesis and you are requesting a power wheelchair to assist you with getting to your
appointments. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to
pre-approve a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpreventive medicine counseling (99403), shingles vaccine (90750), tetanus vaccine (90715) and typhoid vaccine (90691) provided on September 30, 2019You asked the Plan to pay for the counseling and immunizations. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these vaccines were done as a routine encounter and are not covered under Medicare Part B. Additionally, the preventive medicine counseling is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the counseling and immunizations. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the counseling and immunizations. Additionally, per Medicare, CPT code 99403 for preventive medicine counseling, is a non-covered code. Therefore, we decided that the Plan does not have to pay for preventive medicine counseling (99403), shingles vaccine (90750), tetanus vaccine (90715) and typhoid vaccine (90691) provided on September 30, 2019 Benefits for the counseling and immunizations may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341x4) filling tooth 29
(D2392) filling teeth 7, 10 (D2330) filling with posts teeth 15 (D2950) crown tooth 15 (D2750) surgical
extraction tooth 19 (D7210) alveoloplasty (D7311).
You asked the Plan to pre-approve the dental services. You say that the provided records should support the
necessity of the services in dispute. The Plan denied your request. The Plan says dental services rendered by an
out of network provider is not covered under the plan benefits. The plan has confirmed that there are network
providers available to provide the needed services.
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 deep
gum and root cleaning (D4341x4) filling tooth 29 (D2392) filling teeth 7, 10 (D2330) filling with posts teeth 15
(D2950) crown tooth 15 (D2750) surgical extraction tooth 19 (D7210) alveoloplasty (D7311).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveuse of ferumoxytol (Feraheme).You asked the Plan to pre-approveferumoxytol. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the enrollee does not appear to have anemia now nor low iron stores.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 ferumoxytol. Our reviewer says that the enrollee meets the Medicare criteria for use of ferumoxytol. Our physician reviewer found the enrollee has a long history of iron deficiency anemia. She has a microcytosis and low iron stores indicative of an impending anemia from iron stores being low. Given her history she does not absorb oral iron. The use of intravenous iron with ferumoxytol is medically necessary and safeand effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ferumoxytol have been met.Therefore, we decided that the Plan has to pre-approveuse of ferumoxytol (Feraheme).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.