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

We decided that the Plan does not have to pay forthe next generation sequencing (NGS) rendered on July 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. Medicare rules say that NGS is covered for patients with either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. We looked at the file and Medicare rules. The file shows that the enrollee has no personal history of cancer. Based on this information, we decided that Medicare rules for coverage of these services have notbeen met.Therefore, we decided that the Plan does not have to pay forthe next generation sequencing (NGS) rendered on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 7, 2019 to June 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you were unaware that the provider was out-of-network.The Plan denied your request. The Plan says the services were 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 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 the medical services provided on March 7, 2019 to June 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 1, 2019 by an out of network (OON) provider.
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 services were rendered by a non-participating 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 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 the medical services provided on August 1, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder reconstruction (23420) provided on October 10, 2019.You asked the Plan to pay for the shoulder reconstruction. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested service code is not substantiated by the clinical documentation in the medical records submitted for review.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 23420 is reconstructionof complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty).We asked our coder 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 shoulder reconstruction. Our reviewer says that CPT code 23420 does not meet criteria for billing or reimbursement consideration. medical records do not include documentation of a reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty), therefore, the service cannot be verified. Our reviewer found the medical records do not include documentation of a reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty), therefore, the service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder reconstruction have not been met. Therefore, we decided that the Plan does not have to pay for shoulder reconstruction (23420) provided on October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the enrollee is considered low-risk for lung cancer, and all lung nodules were less than 6 mm. A 3-month follow-up CT scan is not medically necessary, according to recommendations.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 18, 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 to the enrollee on July 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for a rhythm ECG (93042) provided on May 24, 2019.
You asked the Plan to pay for the rhythm ECG. You say that you would like reconsideration as this service was billed correctly. The Plan denied your request. The Plan says this service is part of the evaluation and management service as it does not appear to address the findings, relevant clinical issues and comparative data.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 93042 is Rhythm ECG, 1-3 leads; interpretation and report only. 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 rhythm ECG. Our reviewer says that a "rhythm strip interpretation" is documented in the record, it is unclear what this service represents. Our physician reviewer found the record is silent as to the events surrounding the "rhythm strip interpretation" so the billing of CPT 93042 is not supported. 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 rhythm ECG have not been met. Therefore, we decided that the Plan does not have to pay for a rhythm ECG (93042) provided on May 24, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forferric carboxymaltose injections provided from June 18, 2019 to June 25, 2019.You asked the Plan to pay for ferric carboxymaltose injections. You say that the enrollee was unable to tolerate oral iron and was losing iron at a rate too rapid for oral intake to compensate.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these injections were not medically necessary.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 pay for ferric carboxymaltose injections. Our reviewer says that these injections meet the Medicare criteria for coverage. Our physician reviewer found ferric carboxymaltose is Food and Drug Administration (FDA) approved for the treatment of iron deficiency anemia in adults with intolerance to oral iron or unsatisfactory response to oral iron. Therefore, these services were medically reasonable and 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 ferric carboxymaltose injections have been met.Therefore, we decided that the Plan has to pay forferric carboxymaltose injections provided from June 18, 2019 to June 25, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injections for the enrollee.
You asked the Plan to pre-approve Orthovisc. You say that you do not carry Euflexxa. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.
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 Orthovisc is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the patient has tried and failed Euflexxa. The provided medical records do not indicate that Euflexxa would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Orthovisc. 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 Orthovisc injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespinal surgery You asked the Plan to pre-approvespinal surgery. The Plan denied your request. The Plansays 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 pre-approve spinal surgery. Our reviewer says that the requested spinal surgery is not considered medically reasonable and necessary in this case. Our physician reviewerfound that the enrollee is a smoker and there is no documentation of stopping smoking. Additionally, there are no red flags for surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvespinal surgery
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.The enrolleeasked the Plan to pay forthe ambulance services. The enrollee said that he awoke on the date of service but was unable to move or answer questions coherently. The enrollee stated that his caregiver determined that his blood sugar was low and called 911. The enrollee said the responders arrived and treated him, eventually getting his blood sugar to a stable level. The enrollee stated that the services were medically necessary and should have been covered.The Plan denied the enrollee's request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicaredoes not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 3, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 11, 2019.
You asked the Plan to waive the copayment for the emergency room visit.. You say that you were under the impression that you had a $0 copayment for an emergency room visit. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 the emergency room visit provided on June 11, 2019.
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 services are 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on their current functional status and medical stability. 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for services provided on August 17, 2019 through September 7, 2019.
You asked the Plan to pay for the services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that a clinical review was not possible without clinical documentation.
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. The Plan has not forwarded a claim or initial denial to verify what services are at issue and why. The Plan did not submit sufficient information to substantiate the reason for denial. Therefore, we decided that the Plan has to pay for services provided on August 17, 2019 through September 7, 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. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided to the enrollee on August 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that you received a referral for the services. The Plan denied your request. The Plan says there are contracted providers to do the same services in the enrollee's area.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided to the enrollee on August 22, 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 is currently undergoing treatment at an acute care hospital (ACH) having been admitted with respiratory failure following recent coronary bypass surgery. The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube. The enrollee is tolerating ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 5, 2019.
You asked the Plan to pay for the physician's services. You say that you were not aware that this provider did not accept your health plan. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 7, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician service. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says the service was not urgent or emergent in nature. The Plan also says the service could have been provided in network.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 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 the office visit provided on September 7, 2019 by an out of network (OON) provider.