Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLiposomal Doxorubicin, Dexamethasone sodium phosphate, and Lorazepam.You asked the Plan to pre-approveLiposomal Doxorubicin, Dexamethasone sodium phosphate, and Lorazepam. You say that the requested medications are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 contractindicates 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 Liposomal Doxorubicin, Dexamethasone sodium phosphate, and Lorazepam. Our reviewer says that the medications are not medically necessary. Our physician reviewer found upon review of the provided records, there was no evidence suggesting the enrollee had tried and failed an anthracycline-based therapy for her breast cancer diagnosis. The requested combination drug (doxorubicin/dexamethasone/lorazepam) includes an anthracycline medication (dexorubicin) which is appropriate at this stage in treatment, however, there is no indication that the included dexamethasone and lorazepam need to be combined in the same product for the best outcome. These medications could be prescribed separately as-needed. The doxorubicin or other anthracycline medication prescribed alone would not be less effective or create more risk for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gauze and tape provided on March 5, 2020.
You asked the Plan to waive the coinsurance for the gauze and tape. You say that you brought the supplies home from the hospital. You say that the provider shouldn't be involved. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for medical supplies. You have been asked to pay a total of $6.90 for the gauze and tape.
Supply
Allowed Amount
Coinsurance
Member Liability
Gauze
$20
20%
$40
Tape
$14.52
20%
$2.90
TOTAL
$6.90
The gauze and tape fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the gauze and tape provided on March 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital
on June 27, 2020. She received oral medications and had stable vital signs. She required maximal to total assist
with functional mobility. She has no skilled nursing or skilled therapy needs. She does not require skilled
nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary
services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, four 2D oral/facial photographic images, and oral hygiene instructions provided on March 5, 2020.You asked the Plan to pay forthe panoramic x-ray, four 2D oral/facial photographic images, and oral hygiene instructions. You say that the provider's representative informed you that the appointment would not cost you anything, and your insurance would cover the cost.The Plan denied your request. The Plan says these services are not covered benefits.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 forthe panoramic x-ray, four 2D oral/facial photographic images, and oral hygiene instructions provided on March 5, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 16, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because
the services at issue were rendered by separate providers. The Plan denied your request. The Plan says that this
claim contains non-anesthesia services submitted by an anesthesiologist.
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.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the retrobulbar injection have been met. Specifically, this service was rendered by a provider
different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two
codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply
to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered
by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that
the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your
favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on December
16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam provided to the enrollee on March 20, 2020.You asked the Plan to pay forthe eye exam. You say that you were not aware that you had to request to be an in-network provider.The Plan denied your request. The Plan says the provider failed to request prior authorization before rendering services and there is also no evidence of plan directed 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 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. 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 forthe eye exam provided to the enrollee on March 20, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 7, 2019 through January 5, 2020.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from December 7, 2019 through January 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion/replacement of a permanent cardiac contractility modulation system for the enrollee.You asked the Plan to pre-approvethe procedure. You say that this is medically necessary.The Plan denied your request. The Plan says there was no evidence found to consider this device safe and effective.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 procedure is not considered medically reasonable and necessary in this case. In this circumstance treatment with the Optimizer System (CPT 0408T) device has been demonstrated in only one controlled trial to help reduce hospital readmission compared to standard medical therapy. Moreover, the trial was very small (only 160 patients) and the results for the composite endpoint barely reached statistical difference (p=0.048). Therefore the efficacy of the Optimizer System (CPT 0408T) is still uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device should be considered experimental and investigational. Our physician reviewer found the enrollee has refractory congestive heart failure.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-approveinsertion/replacement of a permanent cardiac contractility modulation system for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay fora retrobulbar injection (67500) provided on December 30, 2019.You asked the Plan to pay forthe retrobulbar injection. You say that you would like reconsideration because the services at issue were rendered by separate providers.The Plan denied your request. The Plan says that this claim contains a non-anesthesia service that the American Society of Anesthesiologists has identified as having a one-to-one relationship with a more appropriate anesthesia service code.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.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the retrobulbar injection have been met. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider typeat issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay fora retrobulbar injection (67500) provided on December 30, 2019.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. Ifwe 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 pay fordrug testing provided on August 29, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the code billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to payfordrug testing provided on August 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the administrative and professional pharmacy services provided for home infusion immunotherapy on January 2, 2020 and January 16, 2020 billed with CPT code S9338.
You asked the Plan to pay for the services as billed. You say that the records support that payment should be made for this service. The Plan denied your request. The Plan says this is not a valid code and cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9338 has a status indicator of "I" on the Physician Fee Schedule which means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the administrative and professional pharmacy services provided for home infusion immunotherapy on January 2, 2020 and January 16, 2020 billed with CPT code S9338.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for WATS3D esophageal brush biopsy provided to the enrollee on November 5, 2019.You asked the Plan to pay for the testing. You say that this should be paid for.The Plan denied your request. The Plan says experimental procedures are not covered under the enrollee's 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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found while it is speculated that WATS 3D biopsy testing can potentially improve the management and improve outcomes of patients with Barrett's esophagus and esophageal dysplasia, there is not high-quality evidence in the medical literature demonstrating that such testing improves the management and outcomes of such patients. The documentation does not support that the WATS 3D biopsy testing was medically reasonable and necessary for this 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 the testing have not been met.Therefore, we decided that the Plan does not have to pay forWATS3D esophageal brush biopsy provided to the enrollee on November 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care from January 4, 2020 through January 16, 2020.You asked the Plan to waive the copayment forSNF care. You say that you should not have to paythe copaymentforthis SNF stay becauseyourpriorstayat this facility should not have included the discharge day of December 17, 2019.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the records show your SNF benefit period started with the facility, they billed for six (6) SNF days for dates of service December 11, 2019 through December 17, 2019.  The breakdown of this claim is as follows: The total SNF days used and paid for at 100% of the allowed amount for this SNF benefit period by the Plan was 6 days. Those 6 SNF days correctly billed and paid for at 100% of the allowed amount for December 11, 2019 through December 16, 2019. The discharge date of December 17, 2019 was not counted in your paid SNF days. For dates of service January 4, 2020 through January 16, 2020, the first fourteen (14) days of this SNF stay was paid at 100% of the allowed amount because along with your previousSNF stay equaled twenty (20) SNF daysthat fell within your 60-day benefit period which started December 11, 2019.  The remaining one (1) day (January 15, 2020) of this SNF stay correctly applied a copayment of $178.00 per day for the 21st SNF day. 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 forSNF care from January 4, 2020 through January 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
You asked the Plan to pre-approve radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage for the requested procedure, neurolysis for pain due to sacroiliitis is not medically reasonable. The use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear long-term benefit than standard treatment for chronic sacroiliac joint pain. It does not meet the definition of medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says six visits have been approved to finalize a home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. Your deficits are not so extensive that they require ongoing supervised therapy beyond what was approved the the health plan. The records not indicate that you require the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. You have been approved of enough therapy to be able to transition to a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 additional physical therapy services.