Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro upper extremity orthosis.
You asked the Plan to pre-approve the requested item. You say that traditional occupational therapies have been tried and failed. The Plan denied your request. The Plan says the item is not a covered 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 requested item. Our physician reviewer found that there is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes associated with the use of the MyoPro for upper extremity paralysis/paresis from conditions such as the enrollee's stroke. The MyoPro is not the most appropriate available supply or level of service for the enrollee in this case, considering potential benefits to the enrollee. The MyoPro is not in widespread use based on scientific evidence, and not the standard of care for post stroke hemiparesis. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the requested orthosis is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 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 requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro upper extremity orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion therapy (99601) provided on February 25, 2021.  You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a valid code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a diagnostic facet joint injection.  You asked the Plan to pre-approve a diagnostic facet joint injection. You say that these services are medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are subject to the criteria listed 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 a diagnostic facet joint injection. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found there is no documentation of functional deficit as related to the thoracic spine. There is no description of the type of the member's thoracic pain, and there is no physical exam of the thoracic spine. There is no pain score noted. The documentation by the provider speaks to lower back/lumbar related symptoms. The magnetic resonance imaging scan shows other pathology present that could be the source of this member's pain. The review has determined that the enrollee does not satisfy the criteria for coverage for the requested facet joint injections.  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 diagnostic facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic facet joint injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery (66984) rendered by the OON provider
on May 10, 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 cataract surgery (66984) rendered by the OON provider on
May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services (92014, 92134) provided on October 8, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for ophthalmological services. You say that Medicare and the Plan deductions were not used. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and does not have a referring provider. The Plan has also determined that these services were not urgent or emergent, nor were they approved in advance.

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 ophthalmological services (92014, 92134) provided on October 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the in-person pain management visit (99214) provided on June 23, 2021.

You asked the Plan to waive the copayment for the in-person pain management visit. You say that the services should be covered as you were seen by a physician's assistant and not a specialist. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $35 copayment for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $35 copayment for an in-person pain management visit. The copayment assessed is for pain management services and applies whether they were performed by a specialist or not. Pain management visits fall 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 in-person pain management visit (99214) provided on June 23, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided 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 above.
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. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a
hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record documents a need for physical and occupational
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for IRF care.
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel test provided to the enrollee on
October 6, 2020.
You asked the Plan to pay for the test. You say that this testing will play an important role in establishing
specific somatic tumor and germline mutations which will guide appropriate medical management. The Plan
denied your request. The Plan says this is not medically necessary based on the plan language and reviewed
clinical documentation.
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 pay for the test. Our reviewer says that the requested
services are not considered medically reasonable and necessary in this case. Our physician reviewer found no
provider records have been submitted for review. Therefore, there is no evidence to support that the provided
testing was medically necessary and reasonable to diagnosis or treat the enrollee's condition(s). In general,
panel testing which is inclusive of testing that is not related to a specific symptom or diagnosis, or for which
there are no associated therapies, is not medically necessary or reasonable. The documentation does not support
that the provided panel testing was medically necessary or reasonable.
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 test have not been met. Therefore, we decided that the Plan does not have to
pay for the Tempus gene panel test provided to the enrollee on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on November 28, 2019, through December 3, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation in the case file supports that it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, it was reasonable for the physician to believe you inpatient stay would span two midnights. This means the service was reasonable and necessary. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on November 28, 2019, through December 3, 2019.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for Guardant360 provided on April 8, 2021.  You asked the Plan to pay for genetic testing. You say that this testing was medically necessary and you are the sole provider for this test. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for Guardant360 provided on April 8, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on May 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 injection services provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided from September 28, 2021, to October 5, 2021.

You asked the Plan to pay for the LTACH services. You say that the LTACH services are medically necessary. The Plan denied your request. The Plan says the LTACH services are 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 pay for the LTACH services. Our reviewer says that the LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The reviewer found that you are receiving appropriate care at the present acute care hospital. The reviewer found you do not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Therefore, the reviewer found that the LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and your condition, and able to be furnished safely and effectively only on an inpatient basis. 

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. Specifically, the file does not indicate why the LTACH admission as medically necessary. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided from September 28, 2021, to October 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on June 9, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says that they were previously billed by and paid another provider for this service.  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 substantiate why this was denied and they did not provide evidence the services were already paid. Therefore, we decided that the Plan has to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on June 9, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam (92014), refraction (92015), frames (V2020), bifocal lens (V2200), transition lens (V2715), and polycarbonate lens (V2784), provided on September 29, 2021.  You asked the Plan to pay for the routine vision services. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exceeded the Plan's maximum allowance.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan offers a $200 allowance for supplemental eyewear every year and members are responsible for all costs  over and above the allowance amount..  We looked at the file and the Plan's rules. You have exceeded the Plan's maximum allowance for this benefit. Based on this information, we decided that the Plan's rules for coverage of the routine vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92014), refraction (92015), frames (V2020), bifocal lens (V2200), transition lens (V2715), and polycarbonate lens (V2784), provided on September 29, 2021.