Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the ultrasound of the head and neck (76536) and the 
ultrasound of the abdominal back wall (76770) provided on March 16, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the services provided. 
 
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 enrollees must pay a $0 copayment for Medicare-covered lab services, x-rays, 
diagnostic procedures/tests, and blood services and medical supplies. Additionally, enrollees must pay a $20 
copayment for each diagnostic radiological service. 
 
The Plan says you must pay a $20 copayment for the Medicare-covered diagnostic tests provided. Based on the 
Plan contract, however, you cannot be asked to pay more than a $0 copayment for the diagnostic tests provided. 
The services provided were ultrasounds that are not considered as a radiological procedure or test. Therefore, 
we decided that the Plan has to waive the copayment for the ultrasound of the head and neck (76536) and the 
ultrasound of the abdominal back wall (76770) provided on March 16, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical eye exam (92014) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a medical eye exam. You say that the provider has over thirty years' experience in eye care and you feel this would be the best option for your lens replacement. The Plan denied your request. The Plan says there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. The records provided for review do not show that the services at issue are urgent or emergent. 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 medical eye exam (92014) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99214) federally qualified health center (FGHC) visit (G0467) provided on March 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that Part C organizations are required to pay federally qualified health centers at least the original Medicare rate to out of network providers. You request reconsideration of the prior decision and issue payment for services rendered The Plan denied your request. The Plan says enrollee's 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99214) federally qualified health center (fqhc) visit (G0467) provided on March 11, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: in the long-term care facility with part-time skilled services.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for malnutrition after a gastric surgery and ascites. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 being sent home would put you at risk of additional injury. You say that you are in desperate need of transfer training and new equipment training prior to going home. You say that you were fully independent prior to amputation. The Plan denied your request. The Plan says the guidelines for coverage of care in an IRF have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for peripheral artery disease and a below the knee amputation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your
request. The Plan says the Plan covers 96 one-way trips per calendar year. the 97th trip and beyond is not a
covered benefit.

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.

We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit covers
up to 96 one-way trips per calendar year. Therefore, we decided that the Plan does not have to provide
coverage for additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (80305) provided on June 17, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a drug test. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 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. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a drug test (80305) provided on June 17, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81404, 81407, and 81408) provided on February 5, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services (81404, 81407, and 81408) provided on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 3, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on April 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) provided on February 22, 2021.
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). You say that the Plan should pay this claim. The Plan denied your request. The Plan says radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary.
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 radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). Our reviewer says that the service was not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in efficacy reported in the literature. Therefore, the procedure was 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 radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and electrocardiogram provided on January 4, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit (99214) and electrocardiogram (93000). You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization was not obtained as required.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 for the office visit and electrocardiogram provided on January 4, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).

You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you need to use this device daily. The Plan denied your request. The Plan says this is not a covered item when the enrollee is not undergoing home dialysis.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron HCL.
You asked the Plan to pre-approve Palonosetron HCL. You say that the records provided support that the enrollee needs an antiemetic and is waiting on medication to start the treatment. The Plan denied your request. The Plan says the drug being requested is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Palonosetron HCL. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the requested use of Palonosetron HCL is not FDA-approved for the enrollee's diagnosis. Both Doxil and Avastin are associated with low emetogenic potential. There is no documentation of issues with prior therapy. The use of the requested drug is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-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 Palonosetron HCL have not been met. Therefore, we decided that the Plan does not have to pre-approve Palonosetron HCL.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you did not know that this provider was out-of-network. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT)(E0766). 
 
You asked the Plan to pre-approve the TTFT. You say that the TTFT is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage of the TTFT. The Plan follows Medicare rules. Medicare rules say that Tumor treatment field therapy (E0766) is covered for 
the treatment of newly diagnosed Glioblastoma Multiforme (GBM) only when all of the following criteria are 
met: 
 
1.The beneficiary has histologically confirmed (World Health Organization (WHO) grade IV astrocytoma), 
newly diagnosed, supratentorial GBM; and, 
 
2.The beneficiary has received initial treatment with maximal debulking surgery (when feasible), followed by 
chemotherapy and radiotherapy; and, 
 
3.Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy or 
radiotherapy, whichever is later; and 
 
4.The beneficiary has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) 
criteria; and, 
 
5.The beneficiary has a Karnofsky Performance Score (KPS) of at least 70; and, 6.The beneficiary will use 
TTFT for an average of 18 hours per day. 
 
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 TTFT. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records show the enrollee does not have a 
Grade IV astrocytoma. 
 
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 TTFT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve tumor treatment field therapy (TTFT)(E0766).
Appeal type: Imaging
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 220.2(B). National Coverage Determination (NCD) for Magnetic Resonance Imaging (220.2): Studies have proven that MRA is effective for evaluating flow in internal carotid vessels of the head and neck. However, not all potential applications of MRA have been shown to be reasonable and necessary. All of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck: - MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses; - MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. These conditions include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA in specific diseases. The medical records should clearly justify and demonstrate the existence of medical necessity; and - MRA and CA are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.