Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation with an out-of-network provider.
You asked the Plan to pre-approve out-of-network cardiac rehabilitation. You say that it can cause potentially harmful stress and be dangerous to expect a cardiac patient in need of rehabilitation to make the stressful and nerve-wracking commute for rehab. You say that the out-of-network program is 1.3 miles from where you live, and you can afford to pay for transportation. The Plan denied your request. The Plan says an in-network provider is available.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab programs. The services must be provided in a doctor's office or an outpatient hospital setting. 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 out-of-network cardiac rehabilitation. Our reviewer says that based on the applicable rules, this would not meet CMS medical necessity requirements for out of network care. Our physician reviewer found that you had symptomatic coronary artery disease which has been successfully treated, you have no history of congestive heart failure and was stable at your most recent office visit. Our reviewer says that although inconvenient, there does not appear to be a medical contraindication to travel to the in-network facility for cardiac rehabilitation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network cardiac rehabilitation have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac rehabilitation with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would be better served by a comprehensive rehabilitation program versus a less acute care program. The Plan denied your request. The Plan says you do not meet Medicare criteria for approval of the IRF services.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services (01936 and 01992) provided on March 29, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.
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. In this case, the Plan did not make a final determination within the allotted time frame. We find that the Plan has not provided enough supporting evidence in the case file to deny payment for these services based on Medicare criteria. Therefore, we decided that the Plan has to pay for the anesthesia services (01936 and 01992) provided on March 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on March 16, 2021.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy. 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 physical therapy provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthotic device for the enrollee.
You asked the Plan to pre-approve these services. You say that this device is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of MyoPro orthotic device in the setting of unilateral right upper extremity impairment following a stroke has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested a MyoPro orthotic device is not considered medically reasonable and necessary in this case. The requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and
expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel provided on March 12, 2021.

You asked the Plan to pay for the Tempus panel. You say that this is not an experimental test and will aid in treatment of the enrollee. The Plan denied your request. The Plan says there is no written order in the file, and the Plan was not able to confirm with the provider that this test was ordered.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

The file contains no medical records. There is no order from the treating physician, no records from this physician, or even a copy of the lab results. Tempus has several distinct genetic testing panels, and the file is not sufficient to determine which panel was provided in this case. As such, it cannot be determined if it is eligible for coverage or, if eligible, whether it is medically necessary.

Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided on March 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 15, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic radiographic (x-ray) images (D0330), provided on March 11, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-rays. You say that you received prior authorization for the services. The Plan denied your request. The Plan says you have exhausted your Plan benefit for these services.

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 requested items or services are not among those covered under this benefit.

Specifically, you have exhausted the maximum allowance for the services requested. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic radiographic (x-ray) images (D0330), provided on March 11, 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 an IRF admission is needed for the enrollee to regain maximum functional potential. 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 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, multi-disciplinary 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator (E1390) provided February 5, 2021.

You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you believe you are being charged for services you had already cancelled. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.

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 and related supplies. 

You have been asked to pay total cost share of $25 for the oxygen concentrator ($125 Medicare-allowed amount x 20% coinsurance). This item falls within the durable medical equipment and related supplies benefit category. In this case, the Plan has confirmed that you did not cancel this service until February 2021. 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 the oxygen concentrator (E1390) provided February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for immunofluorescence (88350) provided on May 18, 2021.
You asked the Plan to pay for the immunofluorescence. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records support immunofluorescence for a total of 8 antibodies.
The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied. 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 immunofluorescence. Our reviewer says that the documentation does not support that the additional unit of 88350 was 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 immunofluorescence have not been met. Specifically, the additional unit of CPT code 88350 was billed in excess of the MUE and was not found to be medically necessary Therefore, we decided that the Plan does not have to pay for immunofluorescence (88350) provided on May 18, 2021.
Please note, this is a duplicate claim. CPT codes 88313, 88346, 88348, 88305, 88342 and 8 units of CPT code 88350 were previously processed and paid by the Plan
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 would like the IRF admission covered. The Plan denied your request. The Plan says based on the medical records received, your condition does not meet the Medicare guidelines.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental screening (D0190) provided on June 15, 2021.

You asked the Plan to pay for the dental screening. You say that you called ahead to make sure this dental care would be covered and were given incorrect information. The Plan denied your request. The Plan says the specific service provided is not covered by your dental benefit.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental screening (D0190) provided on June 15, 2021.

Your complaint about possible misinformation from the Plan regarding a specific service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on April 27, 2021.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy. 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 physical therapy provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) machine(E0601) and humidifier (E0562), provided on January 4, 2021, through August 4, 2021.
You asked the Plan to waive the coinsurance for a CPAP machine with humidifier. You say that the item was medically necessary. The Plan denied your request. The Plan says the cost share was applied 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). 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 20% coinsurance for a CPAP machine with humidifier. These items fall within the durable medical equipment (DME) and related 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 coinsurance for a continuous positive airway pressure (CPAP) machine(E0601) and humidifier (E0562), provided on January 4, 2021, through August 4, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic risk panel provided on June 20, 2020, billed with codes 81291, 81407, 81408, 81479, and 81439.
You asked the Plan to pay for the cardiovascular risk panel. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says this type of panel is noncovered.
The Plan must follow Medicare rules. Medicare rules say that cardiovascular risk panels are covered only when billed with certain codes.
The codes billed for this panel are not appropriate. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic risk panel provided on June 20, 2020, billed with codes 81291, 81407, 81408, 81479, and 81439.