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

We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and
management of an established patient (CPT code 99336) provided to the enrollee on September 23, 2019, by an
out-of-network provider.

You asked the Plan to pay for the services. You say that you are seeking reimbursement from the health plan as
your services were rendered in good faith that you would receive payment. The Plan denied your request. The
Plan says the provider is not in-network, there was no prior authorization, and the services were 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. No records were submitted to substantiate medical need,
symptoms, or urgency/emergency need. 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 domiciliary or
rest home visit for the evaluation and management of an established patient (CPT code 99336) provided to the
enrollee on September 23, 2019, by an out-of-network 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 the enrollee will require prolonged hospitalization and close physician monitoring. The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care hospital.
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 physician reviewer found that the enrollee was admitted to the acute care hospital with respiratory failure due to COVID-19 pneumonia. She did not require intubation. She had no complaints and was in no acute distress. The enrollee is on a prolonged steroid taper. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that she requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT perfusion of the brain for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show why the study is needed to assess an acute (abrupt onset) stroke.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has classic evidence of cerebral hypoperfusion and the known bilateral internal carotid artery occlusion with reconstitution of flow into the brain via collaterals make for a challenging scenario. The use of CT perfusion study is very useful as explained in the neurosurgical consultation to look for the flow diminishment expected. The requested CT perfusion study with Diamox challenge will provide valuable information concerning the amount of brain matter affected by ischemia. The enrollee's automatic implantable cardioverter defibrillator is a contraindication to MRI, so the requested test is the best option available to 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve CT perfusion of the brain 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT code 81407) provided to the enrollee on June 23, 2020.

You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your request. The Plan says the genetic testing was not ordered/approved by Ordering provider as per the outreach response.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. The genetic testing was not ordered/approved by Ordering provider. Therefore, we decided that the Plan does not have to pay for the genetic testing (CPT code 81407) provided to the enrollee on June 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sigmoidoscopy with biopsy provided on August 24, 2020.

You asked the Plan to waive the copayment for the sigmoidoscopy with biopsy. You say that you were unaware there would be a copayment. 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 Outpatient Surgery. 

You have been asked to pay a $295 copayment for the sigmoidoscopy with biopsy. The sigmoidoscopy with biopsy falls within the Outpatient Surgery 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 the sigmoidoscopy with biopsy provided on August 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not 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 a Vertiflex Superion device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show
safety and efficacy.

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 Vertiflex Superion device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and preventive procedure (D1999) provided on November 18, 2020.
You asked the Plan to pay for the bone replacement graft and preventive procedure. You say that you needed to see a dentist immediately and were unable to see your in-network dental provider at this time. The Plan denied your request. The Plan says these services are not covered benefits.
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 pay for the bone replacement graft for ridge preservation (D7953) and preventive procedure (D1999) provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor.
You asked the Plan to pre-approve the FreeStyle Libre. You say that you would like reconsideration because
other methods of testing are too painful. The Plan denied your request. The Plan says the records do not show
that you meet Medicare's LCD criteria for coverage.
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 submitted documentation does not include any clinical
information to verify if you have diabetes, perform blood glucose testing at least four times per day, use insulin
at least three times per day and require frequent self-adjustment of your insulin dosage. Based on this
information, we decided that Medicare rules for coverage of the FreeStyle Libre have not been met. Therefore,
we decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the review indicates that there is no documentation 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 they are 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET imaging; whole body (CPT code 78813), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that the enrollee had a computed tomography (CT) of the chest/abdomen showing extensive metastatic disease including a malignant appearing lung mass. The Plan denied your request. The Plan says the enrollee's records do not show that standard imaging or services have failed in assessing their condition.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer found the enrollee's current CT scan has already determined that the enrollee has widely metastatic cancer and it is unclear how a PET CT would be helpful. Additionally, CT imaging is sufficient to target biopsy without the need for a PET scan at this time. It appears the next medically necessary step in the enrollee's care is to obtain tissue biopsy as this will establish a diagnosis and guide initial anti-tumor treatment, which would not be aided by the results of PET CT. Requesting PET CT without obtaining tissue biopsy appears premature. The review has determined that the enrollee does have an indication for which a PET Scan can be covered at this time, however the requested PET Scan is not medically necessary and reasonable for the enrollee at this time. The Medicare criteria covers PET scan for initial diagnosis of lung cancer, it does not cover PET scan for the initial diagnosis of prostate cancer. This further supports the need for tissue biopsy in this enrollee. Without biopsy, it is hard to prove the enrollee does not have prostate cancer alone, which is nationally non-covered for initial staging. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET imaging; whole body (CPT code 78813), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve atezolizumab (J9022), carboplatin (J9045), and paclitaxel (J9267).

You asked the Plan to pre-approve atezolizumab, carboplatin, and paclitaxel. You say that this is medically necessary. The Plan denied your request. The Plan says this drug combination is experimental.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve atezolizumab, carboplatin, and paclitaxel. Our reviewer says that treatment with these medications is not supported. Our physician reviewer found the enrollee has progressed on tecentriq. Tecentriq is only approvable with abraxane, not the requested drug combination. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of atezolizumab, carboplatin, and paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve atezolizumab (J9022), carboplatin (J9045), and paclitaxel (J9267).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on September 16, 2020.

You asked the Plan to pay for the dental service. You say that you have been lied to and taken advantage of financially by the plan. You say that there have been numerous occasions when your dental work was pre-approved. You say that you were told each time that the proposed service would be covered, and each time the claim was denied. The Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan also says that a review of phone calls received from the member from September 3, 2020, to September 10, 2020, did not indicate that the enrollee was advised the consultation would be 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on September 16, 2020.

Your complaint about being misinformed by plan representatives is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vascular surgery services (37799) provided on July 21, 2020.

You asked the Plan to pay for the vascular surgery services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 asked our coder 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 the vascular surgery services. Our reviewer says that CPT code 37799 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that an unlisted procedure, vascular surgery was performed on July 21, 2020, therefore this service cannot be verified. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vascular surgery services have not been met. Therefore, we decided that the Plan does not have to pay for vascular surgery services (37799) provided on July 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says skilled services are no longer required, and the continuation of services 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to provide
medically necessary and reasonable treatment safely and effectively in a SNF. You have no complex wound
care, or other skilled nursing need. Your functional level does not require skilled therapy services with the
specialized skill, knowledge and judgment of a qualified therapist required to provide medically necessary and
reasonable treatment safely and effectively in a SNF. Skilled nursing or therapy services are not required on a
"daily basis" or as a practical matter 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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says the requested provider is not an affiliate contracted provider for outpatient rehabilitation services. Services must be directed by the Plan and an authorization is needed prior to services being rendered.
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 physical therapy. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.