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

We decided that the Plan does not have to pre-approve external cardiac monitoring to be rendered by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested service.
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.
You are not a network provider with the Plan. The Plan has network providers available who can provide the
service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service.
Therefore, we decided that the Plan does not have to pre-approve external cardiac monitoring to be rendered by
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
September 20, 2021, through September 21, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you were seen in the emergency room
because you kept throwing up blood. The Plan denied your request. The Plan says an inpatient admission was
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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that you presented to the emergency department (ED) for evaluation and
management on September 20, 2021. The evaluation revealed acute blood loss anemia, which resolved
following transfusion of two units of red blood cells and upper endoscopy which revealed a non-bleeding,
clean-based duodenal ulcer thought to be the source of bleeding. Blood clotting studies revealed no
coagulopathy. Treatment also included stopping all NSAIDs and initiation of proton pump inhibitors. Your
vital signs remained stable throughout the hospitalization, no further of evidence of bleeding was noted, and
you were deemed safe for discharge on September 21, 2021. The review has determined that the record did not
show that at the time of inpatient admission the admitting physician reasonably expected that your necessary
hospital care (including earlier ED and/or observation 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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from September 20, 2021, through
September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on April 26, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you feel that the testing should be considered diagnostic radiology. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $325 copayment for CT scans. You have been asked to pay the allowed amount of $277.28, which is less than the $325 copayment for a CT scan. A CT scan falls 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 a CT scan provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided March 13, 2021.
You asked the Plan to pay for the tooth extraction. You say that the service should be covered. The Plan denied your request. The Plan says you have exhausted your dental allowance; therefore, the requested service is 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 supplemental dental services up to a $3,000 allowance.
We looked at the file and Medicare rules. The Plan provided documentation showing that the full allowance has been applied to your dental claims prior to processing the claim at issue. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services you
received on May 26, 2021, and May 29, 2021, and the magnetic resonance imaging (MRI) of the arm you had
on June 8, 2021.
You asked the Plan to waive the copayments for the PT services and the MRI. You say that these services were
needed as a result of a reaction you had to the COVID-19 vaccine, so the copayments should be waived. The
Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that
there is no provision in your contract for the waiver of these copayments.
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
copayment per visit for PT services and a $150 copayment for advanced imaging services in a hospital.
You have been asked to pay a $20 copayment per visit for the PT services and the MRI. According to the
Plan's website, the Plan is only waiving copayments for COVID-19 treatment. You did not have COVID-19.
You had a reaction to the vaccine. Treatment for reactions to the vaccine (not COVID-19 itself) are not part of
the Plan's copayment waiver program. Only patients who have a confirmed diagnosis of COVID-19 are
eligible to have their copayments waived. 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 copayments for the
physical therapy (PT) services you received on May 26, 2021, and May 29, 2021, and the magnetic resonance
imaging (MRI) of the arm you had on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 application of a modality to 1 or more areas; infrared, acupuncture visits (97026).
You asked the Plan to pre-approve the acupuncture visits. You say that the enrollee is in constant pain that needs to be managed by acupuncture since it is the only thing that has helped manage the pain. The Plan denied your request.
The Plan says based on the records the other 16 visits and 16 therapies are not medically necessary. The approved services should be enough to complete the enrollee's care and allow the provider to re-assess and submit a new treatment plan.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 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 acupuncture visits. Our reviewer says that the Medicare criteria for coverage for additional acupuncture services were not met. Our physician reviewer found the NCD limits the number of acupuncture visits to 12 visits in 90 days. There is also a clear requirement for documentation of progress made through these visits. Only 8 visits were approved and are medically reasonable and necessary. More documentation of progress and efficacy are needed to approve additional visits. 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 acupuncture visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 application of a modality to 1 or more areas; infrared, acupuncture visits (97026).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of chronic obstructive pulmonary disease (COPD) with chronic respiratory failure. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary.
This enrollee has severe chronic obstructive pulmonary disease (COPD), with mild carbon dioxide (CO2) retention during an emergency department visit for an exacerbation that did not require hospitalization. The enrollee likely has mild nocturnal hypoventilation from COPD and may benefit from BiPAP at night. But Medicare does not cover a ventilator when used as BiPAP. Certain BiPAP devices can provide the AVAPS mode of support. The denial of the home ventilator is upheld. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from April 8, 2021, through
June 8, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed for
medical necessity. The Plan denied your request. The Plan says these services were rendered by a provider who
has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
medical services provided from April 8, 2021, through June 8, 2021, by a provider who has opted out of
Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 4, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a hereditary cancer screening panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the required services are custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided from July 7, 2021 to July 28, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this provider is out of network and is not a Medicare eligible provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan contract also states outpatient mental health care requires prior authorization. The provider is both out of network and a non-eligible Medicare provider. 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 out of network outpatient mental health care provided from July 7, 2021 to July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324).
You asked the Plan to pre-approve Orthovisc. 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 Orthovisc. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee received Supartz in March 2021 with some relief. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternatives. 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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. You are not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal.
We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment to be rendered by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on June 2, 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 subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative approaches. The Plan denied your request. The Plan says this service is considered experimental and investigational.
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 services. Our physician reviewer found that this enrollee is being treated for spinal stenosis in the lumbar region, with neurogenic claudication. She presented with low back pain that she notes is primarily below her waistline. She denies any pain or numbness traveling into her bilateral lower extremities but does notice some pain extending into her left hip intermittently. She notes that sitting down and leaning forward will relieve her pain. Symptoms are consistent with a positive shopping cart sign. She notes in the evening, she can barely walk due to the low back pain. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of a lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Therefore, the requested interspinous device at L3-L4 and L4-L5 is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.