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

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that significant clinical and diagnostic patient-specific data support the medical necessity of Intracept. The Plan denied your request. The Plan says the denial of authorization for Intracept is correct, because studies have not proven that Intracept is helpful for the enrollee's condition.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered to be an experimental/investigational 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 Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the flow cytometry provided on January 12, 2021.  You asked the Plan to pay for the flow cytometry. The Plan denied your request. The Plan says the coverage criteria are not met.  The Plan follows Medicare rules. Medicare rules say that flow cytometry is covered for the indications established in the applicable LCD.   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 flow cytometry. Our reviewer says that the requested flow cytometry was not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 81-year-old female with the diagnosis of leukopenia for approximately one year. She has mild anemia. No intervention was planned. Flow cytometry was performed. Based on the provided records, she is being monitored as she has had stable blood counts and is not undergoing initial workup as she has had this diagnosis for some time. No treatment was started. The enrollee, therefore, does not meet the LCD criteria and the flow cytometry will be considered not medically necessary at this time.  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 flow cytometry have not been met. Therefore, we decided that the Plan does not have to pay for the flow cytometry provided on January 12, 2021.
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 want to return to your prior level of independence. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.    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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this surgery is medically reasonable and necessary for your condition. 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 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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for a knee orthosis with adjustable knee joints (L1833) provided on March 1, 2021.  You asked the Plan to reduce the copayment for a knee brace. You say that you were shocked to see the $877 charge for a basic, adjustable knee brace. You say you understand you are obligated to pay a 20% coinsurance and are not disputing that. You also say you understand the Plan allowed $597.76, which left you responsible for $119.55. However, you say you found multiple online retail sources for the same item at a cost of $200. You asked the Plan to use a fair market value in the range of $200 rather than the inflated value of $877 for the knee brace to base your 20% coinsurance on. You say the copayment should not exceed $40.   The Plan denied your request. The Plan says the claim was processed correctly. The Plan indicated health plans are not authorized to change the billing protocol for medical services. Billing is based on both industry standards and Medicare's coding guidelines. The Plan says the copayment amount was assessed correctly in accordance with these standardized coding, coverage, and payment rules as outlined by the Centers for Medicare and Medicaid Services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable Medical Equipment (DME) and related supplies.   You have been asked to pay a $119.55 copayment for a knee brace. Knee braces fall within the Durable Medical Equipment (DME) and related supplies benefit category. The Plan approved charges of $597.75 for the brace ($597.75 ? 20% = $119.55). The Plan must follow rules outlined by Medicare, including fees and payment of services. 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 reduce the copayment for a knee orthosis with adjustable knee joints (L1833) provided on March 1, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency services provided on November 29, 2019.  You asked the Plan to pay for the emergency services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the emergency services was not filed until December 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency services provided on November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient post hospitalization services provided September 23, 2020, to April 20, 2021, while out of the country.  You asked the Plan to pay for the outpatient service provided while out of the country. You say that you would like these services covered. The Plan denied your request. The Plan says that only emergency services provided outside of the country are covered. The post hospitalization services are not considered emergency services and are not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United States are excluded from coverage except for certain services described in the rules section of this letter. The Plan provides a worldwide coverage benefit that exceeds Medicare coverage. The Plan covers services provided outside of the country only under emergent or urgent circumstances.  We looked at the file and Medicare rules. In this case, based on the documentation provided, the outpatient services at issue do not appear to have been urgent or emergent.  Therefore, we decided that the Plan does not have to pay for the outpatient post hospitalization services provided September 23, 2020, to April 20, 2021, while out of the country.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that this requested device is necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair 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 shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dispensing fee, binaural (V5160) purchased on September 15, 2020.  You asked the Plan to pay for the hearing services. You say that you had paid for the full amount of the hearing aids up front and had not received your refund of $500. The Plan denied your request. The Plan says the maximum benefit has been exhausted.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The records show that the $500 allowance had applied towards procedure code V5261 from the same claim. As the full allowance was applied the benefit maximum has been met. The Plan has also confirmed with the provider that you will be reimbursed $500 as the Plan has paid $500 towards the claim.         We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for coverage of the hearing services have not been met. Therefore, we decided that the Plan does not have to pay for dispensing fee, binaural (V5160) purchased on September 15, 2020.
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 these orthotics will improve your condition and prevent additional complications. 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound provided on July 21, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound was ordered because the facility's bladder scan device was not working. You said that this ultrasound was not needed because the scanning device got fixed and the enrollee's doctor put in a Foley catheter instead.  You said that this test was inconclusive. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for ultrasounds.   The enrollee has been asked to pay a $35 copayment for the ultrasound. This copayment applies regardless of the reason for the test and regardless of the outcome of the test.  This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional (93293) rendered by the out-of-network (OON) provider on July 1, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional (93293) rendered by the out-of-network (OON) provider on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) and laboratory services (81003) provided on May 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the medical services. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 the office visit (99213) and laboratory services (81003) provided on May 6, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder testing rendered on January 4, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.  We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gralise.  You asked the Plan to pre-approve Gralise. You say that Gabapentin failed to control the enrollee's symptoms. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gralise.     Benefits for Gralise may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on November 12, 2020.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered 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 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 laboratory services rendered by the out-of-network (OON) provider on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. A setting with an intensity level below that of an IRF would be more appropriate for your continued therapy.  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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.