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

We decided that the Plan does not have to pay forthe Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923) provided on November 25, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe Ultrasound study of arteries. You say that the physician is in the process of being added to the provider group.The Plan denied your request. The Plan says OON criteria were not met for the service.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 careand 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 items/services at issue in this appeal. The Plan did not pre-approve the item/serviceat 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 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923) provided on November 25, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing and preventive counseling services provided by a chiropractor on September 3, 2020.
You asked the Plan to pay for lab tests and chiropractic services. You say that these services are medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that they have approved payment for the office visit charge, so this denial is only for the lab tests and other non-covered services performed on this date of service.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for laboratory testing and preventive counseling services provided by a chiropractor on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam (99213) provided October 14, 2020.You asked the Plan to waive the copayment forthe eye exam. You say that the eye exam should be considered a glaucoma screening with no copayment.The Plan denied your request. The Plan says the medical records and claim coding support that this was a problem-focused visit based on an existing condition insteadof a screening.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 $45 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.You have been asked to pay a $45 copayment for the eye exam. This servicefalls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based onyour 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 forthe eye exam (99213) provided October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient or outpatient dialysis to be provided bythe requested out-of-network facility.You asked the Plan to pre-approvethe inpatient or outpatient dialysis. You say that the enrolleestarted dialysis with your facility  and due to the rising cases of Covid-19 it is not in the enrollee's best interest to switch clinics.The Plan denied your request. ThePlan says the services are available with an in-network hemodialysis center.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 inpatient or outpatient dialysisat issue in this appeal. We found noexception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approveinpatient or outpatient dialysis to be provided bythe requested out-of-network facility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnbrel SureClick for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered under Part B.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-approveEnbrel SureClick for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a freestyle libre 2 sensor.
You asked the Plan to pre-approve a freestyle libre 2 sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a freestyle libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a freestyle libre 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120 and prophylaxis (D1110) provided on October 14, 2020. You asked the Plan to pay for the dental services. You say that you called the Plan's dental line 5 times. You say that every time you called, the line went dead. You say that you are on a very limited income. The Plan denied your request. The Plan says the provider in this case is out-of-network. The Plan says that dental services that you receive out of network 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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120 and prophylaxis (D1110) provided on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from August 9, 2020, to August 15, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient services were medically necessary.The Plan denied your request. The Plan says that the inpatient services were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found in this casethe admitting physician documented his reasonable expectation that the stay would span two midnights. Relevant clinical considerations included, but are not limited to, the fact that the enrollee is diabetic, had previous episodes of cellulitis and that x-rays were consistent with osteomyelitis in the emergency room. The elements of the controlling rule are satisfied,and a two-midnightstay was reasonably expected.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Planhas to pay forthe acute inpatient hospital care provided from August 9, 2020, to August 15, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing rendered.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that prior authorization is required for genetic testing.The file shows that genetic testing was rendered without prior authorization from 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 forthe genetic testing rendered .
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fordiagnostic services provided  by an out of network (OON) provider.You asked the Plan to pay fordiagnostic services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 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 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 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 fordiagnostic services provided  by an out of network (OON) provider
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 the enrollee was hospitalized with acute kidney failure and primary hyperparathyroidism requiring parathyroidectomy and gastronomy tube placement. Per the medical provider documentation, the acute renal failure is improving and total parental nutrition will be continued for chronic malabsorption leading to vitamin deficiencies due to the effects of prior gastric bypass and chronic celiac disease. The enrollee's prior level of function was independent. Per the therapy assessment, the enrollee is requiring a minimal level assist for bed mobility and moderate assist for transfers. The enrollee's mobility is limited due to pain. Additionally, the enrollee has not required prolonged mechanical ventilation. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says that the item is not medically necessary. Our physician reviewer found you have a personal mobility deficit, but it is not clear that this deficit impairs participation in MRADLs in the home. You currently can propel a manual wheelchair 25 feet and when your prosthesis fit could ambulate with a rolling walker at home and in the community. The documentation does not reveal that you are able to safely operate a PMD in the home.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser eye 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 the best evidence does not indicate the proposed treatment is effective. 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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has developing cataracts and long-standing vitreous degeneration who has about 6 months of worsening floaters.  The record indicates that there is no vision defects. In the absence of a national or local coverage decision, the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k) defines coverage for medically reasonable and necessary services. An article in November 2020 European Journal of Opthalmology concluded that "Vitreolysis with Nd:YAG laser improves visual results in patients with symptomatic vitreous floaters, without adverse events considered clinically relevant. Other trials with a larger number of participants are required to corroborate these results. UpToDate indicates that posterior vitreous detachment (PVD) and do not have any retinal breaks or tears, detachments, or vitreous hemorrhages on a 360 degree peripheral retina examination require only reassurance, education, and a plan for follow-up examination. At this time, the available literature has not established that this procedure is not experimental or investigational in this setting. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve laser eye surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvean office visit (99214) and electrocardiogram (93000).You asked the Plan to pre-approvean office visit and electrocardiogram. You say that you are in active treatment with this doctor.The Plan denied your request. The Plan says that this is not an in-network doctor. You can get medically needed care from a doctor that is not in your primary network if a doctor is not able to provide care.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve an office visit and electrocardiogram. Our reviewer says that continued care with this doctor is medically necessary at this time. Our physician reviewer found that you have activeissues and are undergoing active evaluation for this by the requested doctor. The requested doctor has ordered x-rays and a short-term follow-up visit for the active issues. Transitioning to a new cardiologist may take some time and cause discontinuity ofcare with an active issue being evaluated.Since the requested doctor is already in the process of evaluating this acute issue, medically it would be reasonable for him to complete the current assessment/treatment for the short term. You can then be safely transitioned to an in-network cardiologist for ongoing long-term management of chronic cardiac conditions at that 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 an office visit and electrocardiogram have been met. Therefore, we decided thatthe Plan has to pre-approvean office visit (99214) and electrocardiogram (93000) with the requested out-of-network provider. If the Plandoes 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 doesnot 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 pre-approveBelatacept.You asked the Plan to pre-approveBelatacept. You say that the services are necessary.The Plan denied 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 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 Belatacept. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined thatthe documentation does not support that theBelatacept is medically reasonable and necessary or 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 Belatacept have not been met.Therefore, we decided that the Plan does not have to pre-approveBelatacept.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome visit (99350), diabetes management (G0108), and medical nutrition therapy (97802) provided, by an OONprovider.You asked the Plan to pay forhome visit, diabetes management, and medical nutrition therapy. You say that authorization should not be needed.The Plan denied your request. The Plan says prior authorization was not obtained. The service was not urgent or emergent.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 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 forhome visit (99350), diabetes management (G0108), and medical nutrition therapy (97802) provided , by an OON provider.