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

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says no further out-of-network approvals for outpatient cardiology visits can be approved.
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
a referral to an out-of-network cardiologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on July 3, 2020.by an out of network (OON) provider.You asked the Plan to pay forspecialist services. You say that you do not agree with this being denied.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-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 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 has network providers available who can provide 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 forspecialist services provided on July 3, 2020.by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebevacizumab-awwb (Q5107), leucovorin (J0604), fluorouracil (J9190), and oxaliplatin (J9263).You asked the Plan to pre-approvebevacizumab-awwb, leucovorin, fluorouracil, and oxaliplatin. The Plan denied your request. The Plan says the clinical history and indications submitted do not meet medical necessity.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 bevacizumab-awwb, leucovorin, fluorouracil, and oxaliplatin. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of bevacizumab-awwb (Q5107), leucovorin (J0604), fluorouracil (J9190), and oxaliplatin (J9263) isnot Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. These drugs are not FDA-approved for upper gastrointestinal or pancreatobiliary cancers. In addition, the enrollee has a bowel obstruction for which Bevacizumab would be contraindicated. Our reviewer also found that the use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bevacizumab-awwb, leucovorin, fluorouracil, and oxaliplatin have not been met.Therefore, we decided that the Plan does not have to pre-approvebevacizumab-awwb (Q5107), leucovorin (J0604), fluorouracil (J9190), and oxaliplatin (J9263)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on July 13, 2020.You asked the Plan to pay forthe subsequent nursing facility care. You say that you rely on the facility to obtain authorization.The Plan denied your request. The Plan says you did not request prior authorization.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 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 forthe subsequent nursing facility care provided on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on July 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says an assistant surgeon
was not necessary for this procedure.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to
establish medical necessity. In this case, you billed assistant surgery services for CPT code 36590. The
Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.
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 services. Our reviewer says that the
requested assistant surgeon services were not medically reasonable and necessary in this case. Our physician
reviewer found that port removal is a relatively simple procedure for which the "0" indicator denotes that
assistant surgeon charges are typically not covered. In this particular case, there is nothing in the
documentation to suggest that there was anything unusually complex about the port removal to necessitate an
assistant surgeon. 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 pay for the assistant surgeon services provided on July 6, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a diagnostic cystourethroscopy (52351) provided on March 25, 2020.
You asked the Plan to pay for the diagnostic cystourethroscopy. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says that the documentation submitted
does not support the service billed.
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.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the record indicates that the Plan utilized clinical reports to
substantiate their decision. The submitted record does not include any clinical information or medical records
to verify if the billed code is appropriate. It is the burden of the Plan to substantiate the denial
with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the
Plan has to pay for a diagnostic cystourethroscopy (52351) provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oxygen concentrator.You asked the Plan to pre-approvean oxygen concentrator. You say that the enrollee needs an oxygen concentrator.The Plan denied your request. The Plan says clinical records supporting necessity were requested but not received.The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.We looked at the file and Medicare rules. There are no medical records supporting medical necessity of home oxygen. Based on this information, we decided that Medicare rules for coverage of an oxygenconcentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvean oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on July 2, 2020.
You asked the Plan to waive the copayment for the echocardiography. The Plan denied your request. The Plan says the copayment applied 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $110 copayment for the echocardiography. The echocardiography 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 the echocardiography provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from May 12, 2020, through June 15, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 providerwith the Plan. The Plandid not pre-approve the physician's 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 physician's services provided from May 12, 2020, through June 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound you had at your urologist's office on March 2, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that you cannot afford this copaymentThe 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 an $85 copayment for diagnostic radiological services at any facility other than your PCP's office. You have been asked to pay an $85 copayment for the ultrasound. The ultrasound falls within the diagnostic radiological services at any facility other than your PCP's office 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 forthe ultrasound you had at your urologist's office on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair.You asked the Plan to pre-approvea power wheelchair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested power wheelchair is medically reasonable or necessary.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says that the documentation does not support that the requested power wheelchair is medically reasonable or necessary. Our physician reviewer found the documentation does not reveal why the enrollee's mobility deficit is unable to be helped by a manual wheelchair. The documentation is not clear that the enrollee can safely maneuver the power wheelchairin the home. There is no trial of the power mobility device to ensure enrollee can maneuver this device safely. The enrollee was reported to be forgetful. It is not clear that this power wheelchair will significantly improve participation in mobility related activities of daily living in the home. Therefore, the enrollee does not meet criteria for the requested item.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID 19 and bacteremia.  The enrollee is not intubated/ventilated.  The enrollee is receiving a prolonged course of antibiotics.  There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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-approvelong term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 14, 2020.
You asked the Plan to waive the copayment for emergency care. You say that the Plan told you to go to the emergency room and now you have a $90 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI).
You asked the Plan to pre-approve the MPI services. You say that the enrollee is unable to exercise on a
treadmill and the requested test is medically necessary. The Plan denied your request. The Plan says the
enrollee has not had an EKG since November of 2019 and is not having symptoms currently.
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 MPI services. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has a history of hypertension, hyperlipidemia, stroke, depression and coronary
artery disease including an abnormal stress test in February of 2019 and cardiac catheterization November of
2019 reporting 2 vessel disease in RCA and LCx that has been managed medically, as well as normal LV
ejection fraction. A clinic note dated October 28, 2020 documents no chest pain and a normal cardiac physical
exam. The enrollee has known coronary disease with a stress test from less than 2 years ago and no
documented angina on recent follow up visit. In this circumstance of a clinically stable patient with less than 2
years from a prior stress test, the medical records do not support the medical necessity for repeat stress testing
at this time. There are no documented covered indications for the procedure.
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 MPI services have not been met. Therefore, we decided that the Plan does
not have to pre-approve myocardial perfusion imaging (MPI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable power wheelchair (PWC) controller with required harness and electronic connections.
You asked the Plan to pre-approve the expandable controller and related components. You say that this should be covered. The Plan denied your request. The Plan says the enrollee is physically able to use the individual controls and it is not medically necessary for this to be controlled from the main drive control.
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 expandable controller and related components. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's upper extremity strength and function are sufficient for the patient to control any power options through their own individual switches.
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 expandable controller and related components have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable power wheelchair (PWC) controller with required harness and electronic connections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services provided by a non-participating
provider on June 24, 2020.
You asked the Plan to waive the deductible for lab services. You say that you do not agree with this deductible.
The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1,000 deductible for outpatient diagnostic tests/out-of-network.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $1,000 deductible for outpatient diagnostic tests/out-of-network. This cost sharing is a contractual
obligation that had not been met at the time lab services was received on June 24, 2020. The total amount you
are being asked to pay is $447.89. Therefore, we decided that the Plan does not have to waive the deductible
for lab services provided by a non-participating provider on June 24, 2020.