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

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  You asked the Plan to pre-approve a PET scan. 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 follows Medicare rules. Medicare rules say that FDG PET is covered for the determination of myocardial viability following an inconclusive single photon emission computed tomography (SPECT) test from July 1, 2001, through September 30, 2002.  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 PET scan. Our reviewer says that the services are not medically necessary. Our physician reviewer found at issue is the medical appropriateness and necessity of a cardiac PET scan in the clinical evaluation of exertional dyspnea in a morbidly obese individual. Other modalities of stress testing have not been performed in this enrollee. Guidelines do not support the use of cardiac PET imaging in this role. As a result, at this time cardiac PET scanning would not be considered medically reasonable and necessary in this enrollee's clinical management.  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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for durable medical equipment received on January 21, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied due to no 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. 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 durable medical equipment received on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair glide.  You asked the Plan to pre-approve a stair glide. You say that you need to get carried upstairs when your bathroom is on the second floor. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 2.  You asked the Plan to pre-approve a Freestyle Libre 2. 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. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors.  You asked the Plan to pre-approve Freestyle Libre sensors. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors and related supplies 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 use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Precision Neo blood glucose test strips (A4253).  You asked the Plan to pre-approve Freestyle Precision Neo strips. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says the requested items a Plan-preferred brand.  The Plan must follow Medicare rules. Medicare rules say that MA plans may limit DME to only preferred brands and manufacturer.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle Precision Neo strips have not been met. Specifically, the request is for a non-preferred brand of DME. The case record indicates the requested, non-preferred brand is not a medical necessity in this case. Therefore, we decided that the Plan does not have to pre-approve Freestyle Precision Neo blood glucose test strips (A4253).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lumbar Aurora ZIP fusion procedure.  You asked the Plan to pre-approve a lumbar Aurora ZIP fusion procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a lumbar Aurora ZIP fusion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the lumbar aurora zip fusion procedure remains experimental. More research is needed to show safety and efficacy of 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 a lumbar Aurora ZIP fusion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar Aurora ZIP fusion procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional True Metrix Glucose Test Strips (A4253)  You asked the Plan to pre-approve the additional test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there was a request for more test strips than are usually allowed under the medical benefit.  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 additional test strips. Our reviewer says that the requested additional test strips are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is checking her sugar six times a day and that the plan has approved 200 test strips for 30 days. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  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 additional test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve additional True Metrix Glucose Test Strips (A4253)
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the various services provided to the enrollee from January 4, 2021 to July 22, 2021.  You asked the Plan to waive the copayments for the services. You say that the copayments should be waived. The Plan denied your request. The Plan says the copayments were applied correctly according to your benefits and the services rendered.  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 the applicable copayments for services rendered.   You have been asked to pay a $160 copayment per day for the inpatient hospital services. The services fall within the inpatient hospital services benefit category. This amounts to a $160 copayment for the January inpatient admission and a $480 copayment for February admission.  You have been asked to pay a $225 copayment for each of the imaging services received on March 26, 2021, April 21, 2021 and July 22, 2021. These services fall within the advanced imaging services benefit category.  You have been asked to pay a $325 copayment for the surgery received on April 6, 2021. This service falls within the outpatient surgery benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the various services provided to the enrollee from January 4, 2021 to July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a facet injection of the lumbar sacral.  You asked the Plan to pre-approve a facet injection of the lumbar sacral. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria.  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 facet injection of the lumbar sacral. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has radiculopathy and spinal stenosis. These two confounding pain generators specifically exclude diagnostic MBBs from being covered. Therefore, the request is deemed 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 a facet injection of the lumbar sacral have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet injection of the lumbar sacral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that your feet need support from surgeries. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for carpel tunnel surgery (64721) provided on January 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for carpel tunnel surgery. You say that this service was covered by the patient's previous insurance carrier. The Plan denied your request. The Plan says that authorization was not requested prior to the carpal tunnel surgery and the provider did not check eligibility prior to surgery.  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 carpel tunnel surgery (64721) provided on January 11, 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 a two-step stepping stool.  You asked the Plan to pre-approve the stool. You say that this is needed to get over the bathroom tub rail. The Plan denied your request. The Plan says this item is primarily used by people who do not have a specific medical need for it.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a two-step stepping stool.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for testing services (procedure code 76700) provided to the enrollee on August 11, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed in this case.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for testing services (procedure code 76700) provided to the enrollee on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network urology provider.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.  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 urology provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services (D0150, D0210) provided to the enrollee on August 17, 2021.  You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the plan has already issued reimbursement for these services within the benefit period.  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. The Plan covers dental services with certain benefit limitations.  The file shows that reimbursement was issued for D0150 for a claim from April 6, 2021. D0150 cannot be covered again until April 6, 2022. The file also shows that reimbursement was issued for D0210 for a claim from November 11, 2021. D0210 cannot be covered again until November 11, 2025.    Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services (D0150, D0210) provided to the enrollee on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on July 5, 2021, to July 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 5, 2021, to July 6, 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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you require IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.  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 that on review of the available records you have uncomplicated left below knee amputation. You are medically stable and do not meet Medicare coverage criteria for an IRF admission. With your current medical stability, and no other medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs.  At your current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.  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: Lab
Decision: Favorable

 We decided that the Plan has to pay for the solid tumor genetic analysis provided on May 6, 2021.  You asked the Plan to pay for the solid tumor genetic analysis. You say that it is the responsibility of the ordering physician to request prior authorization. You say the results of the test are medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.  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. The Plan did not show whether the referring physician is an in-network provider or an out-of-network provider. This means we cannot determine if the Plan's denial of the non-emergent service is supported. Therefore, we decided that the Plan has to pay for the solid tumor genetic analysis provided on May 6, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided on August 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing services provided by an OON provider. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 drug testing services provided on August 16, 2021 by an out-of-network (OON) provider.