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

We decided that the Plan does not have to pay for a cardiovascular genetic panel (81286, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided on March 15, 2021.

You asked the Plan to pay for a cardiovascular genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. 

The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular genetic panel (81286, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided on March 15, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.

You asked the Plan to pre-approve Procrit. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Procrit. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the documentation does not support that the enrollee has tried and failed Retacrit. The documentation
does not support an indication that the plan's required drug would likely be less effective and/or likely have
adverse effects for the enrollee. Therefore, the enrollee does not meet step therapy criteria for the requested
drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram services (93010) provided on March 3, 2021.
You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.
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 93010 has a bundled relationship with code 92960 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram services (93010) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on May 4, 2021.
You asked the Plan to pay for the eyeglasses. You say that this is an in-network provider recognized by the Plan. The Plan denied your request. The Plan says this provider is not part of the Plan's routine vision network as specified in the contract.
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 covers one pair of lenses and frames every two years when purchased from an in-network provider. We looked at the file and the Plan's rules. The record shows that the provider in this case is not part of the Plan's network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3030) for the enrollee.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that inserts and other shoe modifications are covered if they are on a shoe that is an
integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. The
Plan follows these same rules.

Records show that the enrollee does not wear a leg brace. Although orthotics may be appropriate for enrollee,
neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided
that the Plan does not have to pre-approve foot orthotics (L3030) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services provided on May 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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 portable x-ray services provided on May 21, 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 an inpatient mental health admission and services.
You asked the Plan to pre-approve inpatient care. You say that the inpatient admission is medically necessary
for the enrollee to detox safely. The Plan denied your request. The Plan says the criteria for an inpatient mental
health admission are not met. The enrollee is considered a low risk for morbidities associated with lorazepam
withdrawal.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient care. Our reviewer says that
the requested inpatient care is not medically necessary in this case. Our physician reviewer found that based
upon review of the records provided, it was not expected that this enrollee would improve in a reasonable
period of time as she did not have dangerousness to self or others, auditory or visual hallucinations or behaviors
threatening acute safety. She was cooperative and compliant with treatment. She was not going through any
symptoms of withdrawal and although this patient does not drink alcohol, her Clinical Institute Withdrawal
Assessment (CIWA) score was found to be less than 3. It did not appear medically necessary and reasonable to
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not
have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears
appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to
herself or others and was cooperative with care without any aggressive behaviors. She had no symptoms of
acute withdrawal. It did not appear that active treatment was taking place. It did not appear that the services
were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Based upon
review the records provided for the admission of this patient does not meet criteria for acute inpatient mental
health treatment as she was not shown to be a danger to herself or others, auditory or visual hallucinations. She
is noted to be cooperative and compliant with treatment while not showing any acute threat to safety. This
patient was not going through any symptoms of acute withdrawal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not
have to pre-approve an inpatient mental health admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another setting, such as an acute
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home 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 reviewer says
that the requested 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 enrollee is receiving appropriate care at the present acute care hospital. The does not enrollee
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.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee 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. Therefore, we decided that the Plan
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on March 31, 2021.
You asked the Plan to pay for an oxygen concentrator. You say that you made a one-time payment which is preferable to paying over $2,000 a year for rental. The Plan denied your request. The Plan says rules for payment for oxygen equipment have not been met.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Specifically, the item at issue was purchased rather than rented. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair (K0001), provided on April 29, 2021.
You asked the Plan to pay for the wheelchair. You say that the item should be covered. The Plan denied your
request. The Plan says you received this item through a provider who is not under contract with the health plan
and is not certified for Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the wheelchair (K0001), provided on
April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on April 27 to
May 17, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for an oxygen concentrator. You say that the requested item was an emergent
necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390)
provided on April 27 to May 17, 2021, by a supplier not enrolled in the Medicare program.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says the request cannot be approved at this time by Medicare or the plan.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental for back pain. More research is needed to show safety and
efficacy.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.

You asked the Plan to pre-approve a walk-in tub. You say that a walk-in tub is necessary for safety. The Plan denied your request. The Plan says a walk-in tub is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower equipment is not covered because this equipment is not primarily medical in nature. While a walk-in shower 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 walk-in tub.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical referral to an out-of-network 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 surgical referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a rollator-upright walker.

You asked the Plan to provide coverage for a rollator-upright walker. You say that this walker is medically necessary. The Plan denied your request. The Plan says the manufacturer of the "UpWalker" you requested is not enrolled in Medicare and has never requested that a billing code be established for this equipment. Therefore, it is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services that are not eligible for Medicare payment. Neither the provider nor the walker requested are eligible for Medicare coverage. Therefore, we decided that the Plan does not have to provide coverage for a rollator-upright walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction and consultation with an oral surgeon.

You asked the Plan to pre-approve the services. You say that you are currently taking blood thinner and need one extraction and another one next year. The Plan denied your request. The Plan says services performed by an oral surgeon are not covered.

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 when the services are provided by a participating general dentist. 

The request is for dental services to be provided by an oral surgeon. This provider type is not covered by your dental plan. 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 pre-approve a dental extraction and consultation with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460), preventive procedure
(D1999), and problem focused limited oral evaluation (D0140) provided on December 15, 2020.
You asked the Plan to pay for the pulp vitality tests, preventive procedure, and problem focused limited oral
evaluation. You say that when you contacted the Plan in November of 2020, you were advised that these
services would be covered. The Plan denied your request. The Plan says the pulp vitality tests and preventive
procedure are not covered benefits under your dental plan. The Plan also says that the problem focused limited
oral evaluation exceeds the frequency limitation in your benefit plan.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the pulp vitality tests (D0460) and
unspecified preventive procedure (D1999) are not among those covered under this benefit. The contract says
that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record
shows that you received a problem focused limited oral evaluation (D0140) on October 26, 2020, and your
problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the
Plan does not have to pay for the pulp vitality tests (D0460), preventive procedure (D1999), and problem
focused limited oral evaluation (D0140) provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services rendered by the out-of-network (OON) provider on October 14, 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 ophthalmology services rendered by the out-of-network (OON) provider on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are not going to get the rehabilitation in a nursing home. You state you need to be in a facility where you can get stronger. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and renal failure requiring hemodialysis. 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. 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 IRF admission and services.