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

We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock (CPT code 15835), excision, excessive skin and subcutaneous tissue (includes lipectomy); leg (CPT code 15833 and excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh (CPT code 15832).
You asked the Plan to pre-approve the services. You say that you have been with your doctors for many years and they have stated these procedures are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you had massive weight loss after bariatric surgery. You have redundant medial thigh tissue and wishes to have this removed at time of panniculectomy. The provided record indicates that the requested procedure is being performed for contouring purposes. The requested procedure is considered cosmetic. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock (CPT code 15835), excision, excessive skin and subcutaneous tissue (includes lipectomy); leg (CPT code 15833 and excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh (CPT code 15832).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of spinal canal.
You asked the Plan to pre-approve magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical (72156). You say that you need this MRI. The Plan denied your request. The Plan says your doctor did not tell us that you have any signs of nerve root damage in your neck.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We looked at the file and Medicare rules. There is no documentation supporting medical necessity for the MRI spinal canal. Based on this information, we decided that Medicare rules for coverage of magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical (72156) have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of spinal canal
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the enrollee does not require skilled nursing or skilled therapy 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating ambulatory facility on June 1, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you believe polyp removal should be considered preventative. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $275 copayment for outpatient surgery/in-network/ambulatory surgical center. You have been asked to pay a $275 copayment for a diagnostic colonoscopy. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the
growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network/ambulatory surgical center 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 for a diagnostic colonoscopy provided by a participating ambulatory facility on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology evaluation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an OON ophthalmology evaluation. You say that you require early intervention. The Plan denied your request. The Plan says this is available in-network.
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 an ophthalmology evaluation to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the nursing facility care (99309) provided on March 6, 2021.
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the provider is not a Medicare certified and SA modifier is non-covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at your request, the file and Medicare rules. Based on this information we have decided that Medicare coverage criteria have been met. Specifically, the provider is non-participating with Medicare, meaning they are eligible for payment at the Medicare allowed rate. Additionally, per Medicare, the practice of issuing denials on the basis that submitted modifiers are not used, has been discontinued. It is the burden of the health plan to substantiate their denial. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the nursing facility care (99309) provided on March 6, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone marrow biopsy procedure you had at an outpatient hospital facility on November 19, 2020.
You asked the Plan to waive the copayment for the bone marrow biopsy procedure. You say that you were told that you would not have to pay for this. You also stated that you believed you would only have to pay $0-$20 for lab services. The Plan denied your request. The Plan says you were charged this copayment 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 a $295 copayment for surgery or other services at an outpatient hospital facility. You have been asked to pay a $295 copayment for the bone marrow biopsy procedure. Biopsies are considered surgical services, not lab services. 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 bone marrow biopsy procedure you had at an outpatient hospital facility on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on May 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and paid due to medical necessity The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 for an outpatient surgery provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and segmental appliance. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for pneumatic compression devices have not been met.

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. The item coded E0667 is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental appliance (E0667).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's high 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. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can stay in the hospital to finish treatments.

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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a ventilator. You say that the enrollee tires easily with exertion. The Plan denied your request. The Plan says the device is not being used as a ventilator with set tidal volume delivery.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our physician reviewer found that in this case, the record indicates the enrollee has chronic obstructive pulmonary disease and sleep apnea. The record indicates that the enrollee is prescribed ventilator settings that can be achieved with a BiPAP machine. The record does not provide sufficient information as to why a portable ventilator is required.

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the auricular stimulator, Dyansys primary relief device (L8679, 64555).

You asked the Plan to pre-approve the Dyansys primary relief device. You say that the enrollee has tried and failed conservative care and medication therapies. Based on history and diagnoses, the provider is recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says this device is not covered by Medicare when used for acupuncture.

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. This device is not a peripheral nerve stimulation device. Acupuncture is only covered for low back pain and Medicare does not cover any auricular simulation device for any indication. Based on this information, we decided that Medicare rules for coverage of the Dyansys primary relief device have not been met. Therefore, we decided that the Plan does not have to pre-approve the auricular stimulator, Dyansys primary relief device (L8679, 64555).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional transportation trips are medically necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation 60 one-way routine transportation trips for the year. Once this benefit is exhausted it cannot be extended. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician office visit provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a physician office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 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 for a physician office visit provided on April 7, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CGM Freestyle Libre 2 Reader, for the enrollee.

You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have 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 use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee is not insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the CGM Freestyle Libre 2 Reader, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99202) provided on April 27, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you visited the clinic for a walk through to see if you liked the facility. You also say you were not aware the facility was going to submit a claim. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $40 copayment for physician/practitioner services, including doctor's office visits with a specialist.

You have been asked to pay a $40 copayment for an office visit. The records show you had a physical examination with a specialist. The EOC confirms $40 is the required copayment for this service. An office visit with a specialist falls within the physician/practitioner services, including doctor's office visits 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 for an office visit with a specialist (99202) provided on April 27, 2021.