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

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided September 4, 2020.

You asked the Plan to pay for the lab services. You say that these tests were medically necessary. The Plan denied your request. The Plan says this was not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. The tests at issue are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on September 10, 2020.

You asked the Plan to waive the copayment for an office visit. You say that this was your annual exam. You say that you should not have a copayment for this. 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 $15 copayment for physician/practitioner services/in-network. 

You have been asked to pay a $15 copayment for an office visit. When services are provided that go beyond an annual visit additional copayment are applied; therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner services/in-network 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 provided by a participating provider on September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel DNA sequencing testing rendered on October 7, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic testing is covered when specific criteria are met. 

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of high-grade pT1bNX leiomyosarcoma. The documentation does not support that the results of the testing will directly impact the treatment or management of the enrollee in this case. The gynecological oncology note dated August 13, 2018 documents that there is not a randomized control trial that supports that therapy will change the course of the enrollee's disease. The testing was therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel DNA sequencing testing rendered on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical first radiographic imaging and a dental crown.

You asked the Plan to pay for the intraoral periapical first radiographic imaging and a dental crown. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

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 intraoral periapical first radiographic imaging and a dental crown.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered not medically necessary and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure because of the wide variation in efficacy reported. Therefore, the request is considered not medically reasonable or necessary 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visits. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are multiple in-network ophthalmology providers available to you which consist of different locations and numerous independent 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 office visits to be 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 acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. 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 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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found the documentation does not indicate that the enrollee has medical needs that would be anticipated to require a stay spanning two midnights. The physician's documentation also does not indicate an expectation of such a need. Therefore, prospective approval of inpatient stay cannot be recommended as a covered service. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam and eyeglasses provided July 22, 2020.

You asked the Plan to pay for the eye exam and eyeglasses. You say that the services should be covered. The Plan denied your request. The Plan says the vision benefit was exhausted at the time the services were provided.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one eye exam and one $200 allowance towards eyeglasses every 12 months. 

We looked at the file and the Plan's rules. The record shows the enrollee previously had an eye exam and purchased eyeglasses on November 15, 2019. 12 months had not passed since this service was provided. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam and eyeglasses provided July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. The enrollee appears to be near baseline function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device rendered on August 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is non-covered. 

We looked at the file and Medicare rules. The services at issue are an intermittent limb compression device billed with code E0676 used during surgery. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device rendered on August 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy can only be on an intensive level in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy can be only on an intensive level in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional LogistiCare mileage.

You asked the Plan to pre-approve additional LogistiCare mileage. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you are requesting an additional 101 miles for a total of 151 miles. Your benefit only allows 50 miles per one-way trip.

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 a maximum of 60 one-way transportation trips per year. Each one-way trip is not to exceed 50 miles. 

We looked at your request, the records in the case file, and the rules. The file shows you are requesting an additional 101 miles for a total of 151 miles. Your benefit only allows 50 miles per one-way trip. Therefore, we decided that the Plan does not have to pre-approve additional LogistiCare mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exhausted the allowable benefit for this item.

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. 

We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this item have not been met. Specifically, the Plan contract states that one upper and/or one lower partial denture is covered once every five years. You previously received an upper partial denture on November 21, 2019, less than five years prior, that was paid for by the Plan. You have exhausted the allowable benefit for this item. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve insertion of a heart failure monitor.

You asked the Plan to pre-approve insertion of a heart failure monitor. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of a heart failure monitor. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in these situations, where there is Class III CHF, complex cardiopulmonary disease and renal insufficiency, managing fluid status using conventional methods is difficult and Cardiomems pressure sensor monitors have been shown in randomized clinical trials to be useful in managing symptoms and preventing rehospitalization and has an FDA indication in this exact clinical situation for its use. Cardiomems device implantation to manage this complex clinical condition is therefore medically necessary and appropriate based on published randomized data and FDA guidelines for its use.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a heart failure monitor have been met. Therefore, we decided that the Plan has to pre-approve insertion of a heart failure monitor.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97530, 97112, 97110).

You asked the Plan to waive the copayment for physical therapy. You say that you believed this copay would only be $15 per session. The Plan denied your request. The Plan says the claim was processed correctly with a $30 copayment per session. Additionally, the Plan contacted the provider who stated that they did not agree to a lower copayment for these services.

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 $30 copayment for outpatient rehabilitation services.

You have been asked to pay $390 for 13 sessions of physical therapy ($30 copayment x 13 sessions = $390). Physical therapy falls within the outpatient rehabilitation services 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 physical therapy services (97530, 97112, 97110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says that you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the nurse practitioner services. 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 nurse practitioner services.