Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (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 member is receiving appropriate inpatient acute care and does not require transfer to an LTACH.

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 he is currently receiving care. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (GCM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you have been using this device and
do not want to go back to finger prick testing. The Plan denied your request. The Plan says the requirements for
coverage of a CGM 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 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (GCM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76641) provided on September 5, 2020.

You asked the Plan to waive the copayment for an ultrasound of the breast. You say that this ultrasound is medically necessary, and you should not have to pay a copayment. 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 $155 copayment for outpatient diagnostic tests and therapeutic services and supplies including an ultrasound.

You have been asked to pay a $155 copayment for an ultrasound of the breast. The EOC confirms $155 is the required copayment for this service. The EOC also confirms a diagnostic mammogram is a covered service with a $0 copayment yearly; however, ultrasounds are not. An ultrasound of the breast falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound of the breast (76641) provided on September 5, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for AlloSure genetic testing provided on December 15, 2020.

You asked the Plan to pay for AlluSure test. You say that this test is covered by Medicare and the Plan must
pay no less than the Medicare allowed rate regardless of your network status. The Plan denied your request.
The Plan says that this testing was not medically necessary.

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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or outof-
network with the Plan. The documentation submitted does not include prior notice from the Plan that this
testing would not be covered. Without this information, we cannot determine whether the lab order made
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for AlloSure genetic
testing provided on December 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON physical therapy. You say that the requested OON provider is about 1 minute from your home and the route is to get there is very flat. You say that you are very limited in your mobility. You say that you do not drive. The Plan denied your request. The Plan says physical therapy is available in network and going OON is not medically necessary.

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. Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. 

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. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide physical therapy. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additive for enteral formula (B4104).

You asked the Plan to pre-approve additive for enteral formula. You say that your sole-food source does not contain enough fiber for your system to function properly. The nutritionist specifically recommended this supplement as the available over the counter equivalent does not do the job. The Plan denied your request. The Plan says this item is not separately payable.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The rules say that code B4104 is an enteral formula additive. The enteral formula codes include all nutrient components, including vitamins, mineral, and fiber. Therefore, code B4104 will be denied as not separately payable. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve additive for enteral formula (B4104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that the monitor will help maintain her blood sugar. The Plan denied your request. The Plan says the guidelines were not 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 does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or requires 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary to manage your diabetes. The Plan denied your request. The Plan says the criteria for coverage 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 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation with a dentist or physician other than the requesting dentist or physician (D9310) and panoramic x-ray (D0330) provided on January 19, 2021.

You asked the Plan to pay for the consultation and x-ray. You say that you were referred to this dentist by another provider in the same dental group and did not realize that they were not part of the same dental insurance networks. The Plan denied your request. The Plan says the consultation is not a covered service, regardless of the network status of the provider. The panoramic x-ray has been covered and paid up to the Plan's maximum payable fee for this service, but because this service was received from an out-of-network provider, they are allowed to bill you for the additional costs up to the full billed amount. These claims were processed correctly.

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 consultation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the diagnostic consultation with a dentist or physician other than the requesting dentist or physician (D9310) provided on January 19, 2021.

The provider billed the Plan $145 for the panoramic x-ray. The Plan's maximum payable amount for this service is $65.79, and the Plan has provided this full amount in payment. Dentists in the Plan's dental network have agreed to accept this amount as payment in full and not charge any additional amount for this service. However, out-of-network dentists do not have this agreement and are allowed to bill for the difference between the Plan's payment and the full billed amount. ($145 - $65.79 = $79.21). This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the panoramic x-ray (D0330) provided on January 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET scan provided to the enrollee on February 23, 2021.

You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The Plan says this was not reported with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they reported properly. 

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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the PET/CT was done 2/23/21 with an indication dictated as: "Breast Cancer." The PET/CT was medically necessary but the CMS rules state that a location and type of the breast cancer must be included in the history/indication to provide a basis for reimbursement and such coding was not supplied. 

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 not been met. Therefore, we decided that the Plan does not have to pay for a PET scan provided to the enrollee on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hemoglobin A1C level test (CPT code
83036) and basic metabolic panel (CPT code 80048) provided on March 3, 2021.

You asked the Plan to waive the copayment for the laboratory testing. You say that this is an error because you
believe your insurance covers routine blood work. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received the laboratory services on March 3, 2021. Medicare recognizes
certain laboratory tests as part of the yearly wellness visit, and therefore, they would be covered in full.

However, the Plan obtained records from your provider, and verified that the Basic Metabolic Panel test, (CPT
code 80048), and the Hemoglobin; glycosylated (A1C) test, (CPT code 83036), are not part of the Medicare
laboratory tests that are covered in full. Therefore, you are asked to pay a $10 copayment for the laboratory
tests. 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 hemoglobin A1C level test (CPT code 83036)
and basic metabolic panel (CPT code 80048) provided on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary tract infection panel testing provided on June 9, 2020.

You asked the Plan to pay for the testing services. You say that the codes are payable. The Plan denied your request. The Plan says the testing is considered unproven.

The Plan must follow Medicare rules. Medicare rules say that diagnostic testing must be ordered by the physician for a specific medical problem.

We looked at the file and the rules. There is no valid physician order. The medical records do not clearly document the intent for the panel testing to be performed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection panel testing provided on June 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device remains experimental. More research is needed to show safety and efficacy of the device. High failure rates with similar devices have been reported. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are available providers within the network that can render the requested 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 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 services at issue in this appeal. 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 home health services to be rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic manipulative treatment (98940) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the chiropractic services. You say that this provider has spinal decompression and laser therapy that you would like to try. This provider has success with spinal therapy. You are desperate and they do not recommend surgery for your back because of your age. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the chiropractic manipulative treatment (98940) 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 IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you cannot swallow when eating and cannot move
your right side because of stroke. You state the doctors are trying to prevent putting in a feeding tube because
they do not want you to have surgery because it puts you at risk. The Plan denied your request. The Plan says
the stay is not medically necessary.

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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
right hemiplegia, dysphagia and a stroke. Medical conditions are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.