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

We decided that the Plan does not have to pay for the FoundationOne CDx testing provided on November 10,
2020. You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 79-year-old female with malignant neoplasm of the bladder, unspecified. Based on the provided documentation and the diagnosis of bladder cancer, there was insufficient support made for this comprehensive gene test, which appeared excessive for the enrollee's needs. Furthermore, it was not clear as to how the results of the entirety of these test results would specifically help the enrollee change treatment and have an improved overall outcome. Therefore, this request for FoundationOne CDx will be considered 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing provided on November 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) level of care provided from July 1, 2020, to July 19, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled nursing or therapy services.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) level of care provided from July 1, 2020, to July 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that these supplies are medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery.
You asked the Plan to pre-approve the requested services. You say that the enrollee is scheduled for surgery. The Plan denied your request. The Plan says the enrollee has not tried conservative therapy.
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 the enrollee presented with left shoulder pain that has been worsening over the past weeks. She reports pain with range of motion, and tingling and numbness in her whole left arm down to her hands. There is left neck pain as well. Detailed documentation is not evident regarding a trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There are limited objective exam findings to fully corroborate disabling deficits. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for total shoulder arthroplasty 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 shoulder surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99214, 90833) provided on January 21, 2021.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 service 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 outpatient mental health services (99214, 90833) provided on January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 28, 2021, to February 2, 2021.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 28, 2021, to February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95938 and the needle electromyography services coded 95861 provided on August 3, 2020.
You asked the Plan to pay for the short-latency somatosensory evoked potential study and the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not supported by the documentation.
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 95938 and 95861 are not supported in the medical record. Specifically, the billed place of service of 15 (mobile unit) is not supported. The documentation supports that the enrollee received services in a facility setting. Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential study and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95938 and the needle electromyography services coded 95861 provided on August 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided May 8, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 97110 is not supported in the medical record. Specifically, the record shows the services were provided in the home setting. There is a more appropriate code for the service billed (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided May 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay from February 8 through February 23, 2021, and the radiologic examination (74230) received February 26, 2021.
You asked the Plan to waive the copayments for the inpatient hospital stay and the radiologic examination. You say that the copayments should be waived due to COVID. The Plan denied your request. The Plan says the diagnosis codes show no COVID-related procedures on the claims so waiving of cost share does not apply to 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 $1400 copayment for Inpatient Hospital Services, and 20% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services.
You have been asked to pay a $1400 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital Services benefit category. You have also been asked to pay 20% coinsurance ($32.56 = 20% of $129.03) for the radiologic examination. The radiologic examination falls within the Outpatient Diagnostic Tests and Therapeutic Services 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 copayments for the inpatient hospital stay from February 8 through February 23, 2021, and the radiologic examination (74230) received February 26, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Temozolomide.
You asked the Plan to pre-approve Temozolomide. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Temozolomide. Our reviewer says that the medication is medically necessary. Our physician reviewer found the requested medication is approved with radiation as adjuvant treatment followed by temazolomide and TTF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Temozolomide have been met. Therefore, we decided that the Plan has to pre-approve Temozolomide.
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. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need frequent physician management or an interdisciplinary approach to rehab care.
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 physician reviewer found that you were admitted to the acute care hospital for right sided weakness, atrial fibrillation, and a urinary tract infection. Your medical conditions are stable. There are no complex nursing needs. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the oral evaluation and x-ray. We decided that the Plan does not have to pay for the pre-diagnostic testing.
You asked the Plan to pay for the dental services. You say that you last received these services while you were in Colorado. You say that you have moved since. You also say that it was necessary for the provider to perform these services in order to establish you as a new patient as they do not have access to your records from Colorado. The Plan denied your request. The Plan says that coverage for a comprehensive oral evaluation is limited to once every 3 years. The Plan says that coverage for a complete series x-ray is limited to once every 5 years. The Plan says that the frequency limits have been exceeded. The Plan also says that adjunctive pre-diagnostic testing is not listed as a covered service.
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.
We decided that the Plan has to pay for the oral evaluation and the x-ray.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Specifically, the frequency limits have not been exceeded for these services. The record shows that the comprehensive oral evaluation and complete series x-ray were paid while you were enrolled in a different plan. Therefore, we decided that the Plan has to pay for the oral evaluation and the x-ray.
We also decided that the Plan does not have to pay for the pre-diagnostic testing.
Though the Plan offers a dental benefit in excess of Medicare coverage, the adjunctive pre-diagnostic testing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pre-diagnostic testing.
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. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the most appropriate level of care for the enrollee to get the necessary help he requires and to reach the goals set for him. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was readmitted with fever and leukocytosis after being discharged earlier that day from an admission for cervical fracture following a fall. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Evenity. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the enrollee does not have post-menopausal osteoporosis. The documentation does not support that the Evenity is medically reasonable and necessary for the enrollee. The documentation does not support that the Evenity is safe and effective for the 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of the extremity veins.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says medical notes were not received.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there were insufficient medical records to show the requested testing was reasonable or necessary. The file shows that the Plan requested medical records on several occasions, but none were obtained. 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 a duplex scan of the extremity veins.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services (00912) provided April 19, 2021.

You asked the Plan to pay for the anesthesia services. You say that the service was medically necessary and billed using the correct QZ modifier, to denote a service performed by a CRNA without medical supervision. The Plan denied your request. The Plan says that the service cannot be paid as billed because a claim for anesthesia medical supervision was submitted on the same date of service.

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. Specifically, no documentation was provided to show that the procedure at issue was the same procedure that was billed on the same date of service with medical supervision. Therefore, we decided that the Plan has to pay for anesthesia services (00912) provided April 19, 2021.

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. If we decide to open the case again, we will send you a letter.