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

We decided that the Plan does not have to pre-approveMonovisc injections.You asked the Plan to pre-approveMonovisc injections. You say that the requested Monovisc injections are medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail hyalgan, hymovis, and synvisc first.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 Monovisc injections. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the left knee. The Plan requires a trial of drugs Hyalgan, Hymovis, and Synvisc first before they will approve the requested drug, Monovisc. The documentation does not show that the enrollee has tried Hyalgan, Hymovis, and Synvisc first. The documentation does not support that Hyalgan, Hymovis, and Synvisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc injections have not been met.Therefore, we decided that the Plan does not have to pre-approveMonovisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and osteopathic manipulative treatment (98927) provided on December 17, 2019 through February 10, 2020.
You asked the Plan to pay for the office visit and osteopathic manipulative treatment. You say that you would like reconsideration because this provider is the only provider in the state that renders these services and these services have greatly improved your quality of life. The Plan denied your request. The Plan says this provider is not under contract with the health plan and is not certified for 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. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for an office visit (99213) and osteopathic manipulative treatment (98927) provided on December 17, 2019 through February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe interpretation of a blood smear (85060) provided on February 24, 2020.You asked the Plan to pay forthe interpretation of a blood smear. You say that you would like reconsideration because this service was rendered in an appropriate place of service.The Plan denied your request. The Plan says CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 85060 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 85060 has a status indicator of 8. This means that no payment is recognized for CPT code 85060 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. Based on this information, we decided that Medicare rules for coverage of the interpretation of a blood smear have not been met.Therefore, we decided that the Plan does not have to pay forthe interpretation of a blood smear (85060) provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from February 18, 2020 to March 10, 2020.
You asked the Plan to waive the copayments for the wound care. You say that you do not believe a leg dressing change is a surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $350 copayment per date of service at an outpatient hospital facility. You have been asked to pay a total of $723.71 copayment for the wound care. The wound care falls within the "Outpatient surgery, including services provide at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that wound care is considered a surgical procedure.

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 wound care provided from February 18, 2020 to March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan for qualitative evaluation of coronary calcium.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have increased coronary risk but no evidence of current heart disease. In this circumstance, aggressive risk factor modification without additional evaluation is indicated regardless of the results of a CT for coronary calcium scan. The current guidelines do not recommend the scan for your condition and the services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan for qualitative evaluation of coronary calcium.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing panels provided on August 16, 2019.You asked the Plan to pay for the drug testing panels. You say that this testing was medically necessary as ordered by the treating provider.The Plan denied your request. The Plan says the order form does not clearly indicate what testing is being requested.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the enrollee's treating provider.In this case, the order form indicates numbered panels which do not clearly define the testing being requested. A form defining the provider's custom panel is included but it is not clear from the order form that the provider intended to order this panel. Without clear delineation of the requested testing, we find that the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing panels provided on August 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from July 9, 2020 and forward.
You asked the Plan to pre-approve the continuation of inpatient mental health care from July 9, 2020 and forward. You say that the continuation of inpatient mental health care from July 9, 2020 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from July 9, 2020 and forward is not medically necessary.
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 the continuation of inpatient mental health care from July 9, 2020 and forward. Our reviewer says that the continuation of inpatient mental health care from July 9, 2020 and forward is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of chronic schizophrenia. He was admitted to the behavioral health center on 6/5/20. The enrollee was described as irritable and withdrawn. He has intermittently refused medications. The enrollee was given IM Haldol, Ativan, and Benadryl on 7/9/20. The enrollee was noted to be safe on a locked unit on 7/11/20, and his disposition was noted to be "in progress". On 7/14/20, the enrollee was aggressive and hostile with an explosive outburst. On 7/13/20 and 7/16/20, the enrollee's clozapine dosing regimen was changed.
He was admitted to the hospital for bipolar disorder. He was agitated and having delusions. He was doing better with treatment. His diagnosis was updated to Dementia. He was eating and sleeping well. He was intrusive. His medical conditions are stable. He does not have any other medical problems that would keep him in the hospital. He is refusing medications. He is currently not yelling or aggressive. He is able to be redirected. He is going to transition to a state psychiatric hospital. Psychiatric hospitalization while waiting for placement is not an active treatment. This is why his request cannot be approved. 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 continuation of inpatient mental health care from July 9, 2020 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from July 9, 2020 and forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction (64635).
You asked the Plan to pre-approve paravertebral facet joint nerve destruction. You say that this is necessary to treat the enrollee's pain. The Plan denied your request. The Plan says the enrollee has had only one set of MBBs.
The Plan must follow Medicare rules. Medicare rules say that the requested service is covered only when dual medial branch blocks (MBBs) provide > 80% relief of the primary or index pain and duration of relief is consistent with the agent employed. We looked at the file and Medicare rules. The record shows that the enrollee has not had dual MBBs as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint nerve destruction have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction (64635).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 26, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on August 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant/NEXT-generation molecular genetic pathology testing provided on February 27, 2020.You asked the Plan to pay forthe Guardant/NEXT-generation molecular genetic pathology testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 81120, 81121, 8117381201, 81210, 8123581270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, and 81403 are not supported in the medical record. Specifically, this service should be coded with code 81479. In addition, the approved DEX Z-Code entered adjacent in the comments/narrative field for the test, not unbundled to separate codes. Based on this information, we decided that Medicare rules for coverage of the Guardant/NEXT-generation molecular genetic pathology testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant/NEXT-generation molecular genetic pathology testing provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for trigger point injections provided on December 31, 2019.
You asked the Plan to pay for the trigger point injections. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
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 trigger point injections provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) and injection (64455) provided on February 18, 2020.You asked the Plan to pay for the office visit and injection. You say that you would like reconsideration because the CPT codes and diagnosis codes are covered by, payable under and rendered in accordance to plan directed care.The Plan denied your request. The Plan says two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting.The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit and injection have not been met. Specifically,the record includes separate diagnosis codes for the left and right. There are bilateral diagnosis codes which would be more appropriate to report in this instance.Therefore, we decided that the Plan does not have to pay for an office visit (99203) and injection (64455) provided on February 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician
reviewer found the medical records do not show that you require skilled nursing or skilled therapy services on a
daily basis. Your condition 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 services have not been met. Therefore,
we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on December 10, 2019 by an out of network (OON) provider. You asked the Plan to pay for a home visit. You say that you were given incorrect insurance information from the patient. The Plan denied your request. The Plan says prior authorization was not obtained.
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 for a home visit provided on December 10, 2019 by an out of network (OON) 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not meet criteria for admission to an IRF. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 18, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 laboratory services.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 laboratory services provided on March 18, 2020.
Appeal type: Practitioner Services
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 this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 radiofrequency ablation is considered an experimental/ investigational procedure because of the wide variation in efficacy in the peer reviewed literature. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 28, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on May 28, 2019.