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

We decided that the Plan does not have to pay for the functional MRI (fMRI) of the brain provided on March
26, 2021.

You asked the Plan to pay for the functional MRI of the brain provided on March 26, 2021. You say that the
functional MRI of the brain provided on March 26, 2021, was medically necessary. The Plan denied your
request. The Plan says the functional MRI of the brain provided on March 26, 2021 was 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 pay for the functional MRI of the brain provided on
March 26, 2021. Our reviewer says that the functional MRI of the brain provided on March 26, 2021, was not
medically necessary. Our physician reviewer found the member in this case was noted to have previously
suffered a stroke in 2020. The member's diagnosis had been confirmed via imaging studies at that time. The
performance of fMRI for cerebrovascular study is not otherwise a service that is currently an accepted standard
of medical practice for the diagnosis or treatment of the enrollee's condition. Such testing/evaluation (that is
testing using fMRI) is largely limited to the academic/research setting at this time. The results of such imaging
have not been shown to provide any meaningful information to providers. Nor has such testing been shown to
lead to an improvement in patient diagnoses, recovery or treatment strategies. As such at this time the service
would not have been reasonable and necessary at the time when it was provided.

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 functional MRI of the brain provided on March 26, 2021, have not been
met. Therefore, we decided that the Plan does not have to pay for the functional MRI (fMRI) of the brain
provided on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids monaural in ear (V5050) provided April 16, 2021.

You asked the Plan to pay for the hearing aids. You say that you are due additional reimbursement. The Plan denied your request. The Plan says the claim has processed correctly. You paid more because you used an out-of-network provider.

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 Plan pays for hearing aids when provided out-of-network with 20% coinsurance based on the Medicare payment rate for participating providers. 

We looked at the file and the Plan's rules. The Plan provided coverage of the hearing aids based on the Medicare payment rate for participating providers ($1,250). You were responsible for 20% of the Medicare payment rate plus your out-of-network provider may bill you for the difference between the Medicare payment rate and the total cost billed by the provider. Therefore, we decided that the Plan does not have to pay for the hearing aids monaural in ear (V5050) provided April 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the Plan requires a trial of drug Zoledronic Acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are
receiving appropriate inpatient acute care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that you were admitted to the acute care hospital for pneumonia. There is no documentation
provided indicating medical necessity for admission to a LTACH. You are receiving appropriate care at the
present acute care hospital. You do not require services at the LTACH that are not available at the acute care
hospital where he 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. The requested LTACH services
are not medically 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging you received on April 13, 2021.

You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you cannot do a treadmill test because of your medical conditions, so this should be covered. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that these services were not denied, this is just the cost sharing that is applicable.

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 $250 copayment for diagnostic radiology services other than computed tomography (CT) scans.

You have been asked to pay a $250 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the diagnostic radiology services other than computed tomography (CT) scans 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 myocardial perfusion imaging you received on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection(s), of diagnostic or therapeutic substance(s) not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) provided on March 4, 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 the copayment has been applied correctly to the service 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 $410 copayment for each covered surgery or surgical procedure performed as an outpatient at a hospital.

You have been asked to pay a $410 copayment for the outpatient surgical procedure provided. 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 injection(s), of diagnostic or therapeutic substance(s) not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) provided on March 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need skilled services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not show that the enrollee has any skilled nursing or therapy needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on March 29, 2021.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the PET scan was billed with an inappropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used.
We looked at the file and Medicare rules. The PET scan in this case was billed with diagnosis code C50.911. This is not an approved diagnosis code to use for a PET scan. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88342) provided on March 11, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate
service.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pay for the services (88342) provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic colonoscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the need for a diagnostic colonoscopy is not warranted at this time.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee underwent colonoscopy in December 2015 that was normal. The
record indicates that the enrollee has chronic gastrointestinal symptoms that have not changed. The enrollee has
not had weight loss. Laboratory studies indicate that inflammatory bowel disease is unlikely. The enrollee has
not been treated for either her reflux or presumed irritable bowel disease. The record does not indicate that the
enrollee has one of the enumerated conditions in the coverage criteria. 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a diagnostic colonoscopy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee is receiving appropriate inpatient acute care and does not require transfer.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that the enrollee was admitted to the acute care hospital for cardiac arrest. His hospital course
was complicated by severe metabolic acidosis, and hypertensive urgency. There is no documentation provided
indicating medical necessity for admission to an LTACH. The enrollee is receiving appropriate care at the
present acute care hospital. He does not require services at the LTACH that are not available at the acute care
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee
requires that are not available at the health care setting being offered by the health plan. Therefore, the
requested LTACH services are not medically 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the nebulizer rendered on June 10, 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 that the claim was not filed timely.
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 states that the claim was not filed timely; however, the file shows that the appeal was received on May 25, 2021 within one year of the date of service. The Plan has not provided any documentation to support that the claim is not payable. Therefore, we decided that the Plan has to pay for the nebulizer rendered on June 10, 2020.
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 waive the coinsurance for lab services you received from an out-of-network provider on December 10, 2020.

You asked the Plan to waive the coinsurance for the lab services. You say that the pain clinic said they were not going to use your insurance card. You do not know what this bill is for. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You received drug testing lab services from this out-of-network provider.

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 50% of the Medicare-allowed amount for out-of-network lab services.

You have been asked to pay 50% of the Medicare-allowed amount for the lab 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 waive the coinsurance for lab services you received from an out-of-network provider on December 10, 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 these services are medically necessary. The Plan denied your request. The Plan says that your 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for a stroke with hemiparesis and was discharged to skilled nursing on June 25, 2021. You were then discharged home on July 6, 2021. You have ongoing weakness at home. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 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. Our physician reviewer found that your 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.
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 the enrollee would benefit from aggressive inpatient
rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF
admission.

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 the enrollee's 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, multidisciplinary
rehabilitation program. There is not a reasonable expectation that the 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.