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

We decided that the Plan does not have to pay forlab work provided on December 13, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that these services were referred to you.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.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 forlab work provided on December 13, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveProlia (J0837).You asked the Plan to pre-approveProlia. You say that you are due for your second dose.The Plan denied your request. The Plan says that step therapy requirements have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the criteria for coverage of Prolia have been met. Our physician reviewer found the Medical Prior Authorization Form indicates that this request for Prolia is a continuation request. The documentation supports that Prolia was new therapy as of January, 2020. Your current osteoporosis regimen is Prolia every 6 months. Step therapy may only be applied to new prescriptions oradministrations of Part B drugs for enrollees that are not actively receiving the affected medication.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met.Therefore, we decided that the Plan has to pre-approveProlia (J0837).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided to the enrollee on February 26, 2020.
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says the services were not medically necessary.
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 pay for the therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the medical records provided do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, that the services could have been safely and effectively performed only by a therapist, or under the supervision of a therapist. The specialized skill, knowledge and judgment of a qualified therapist was not required to establish, design and/or deliver a program to maintain the enrollee's 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 therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided to the enrollee on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on February 26, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 1, 2020. 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 February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling provided to the enrollee on February 22, 2020.
You asked the Plan to pay for the profiling. You say that this should be paid for. The Plan denied your request. The Plan says procedures shall be reported with the most comprehensive CPT code that describes the services performed.
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 81479 is "unlisted molecular pathology procedure." We find that the multitude of denied codes are not supported in the medical record. Specifically, this claim should have been coded with a single code - CPT 81479, as the Guardant360 test was provided. Based on this information, we decided that Medicare rules for coverage of the profiling have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling provided to the enrollee on February 22, 2020.
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 you disagree with the denial. The Plan denied your request. The Plan says the requested IRF care is not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 8, 2020 with uncontrolled pain. He has a history of squamous cell lung cancer with brain metastases. The complexity of his nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program in an IRF. 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: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device.You asked the Plan to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain radiating into the legs. The documentation supports that the requested device is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) provided on February 13, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) provided on February 13, 2020 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional unit of CPT 73720 provided on February 4, 2020.You asked the Plan to pay foran additional unit of CPT 73720. The Plan denied your request. The Plan says the records support one MRI.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 73720 is "Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences".We find that CPT code 73720 is not supported in the medical record. Specifically, the records show that one MRI was provided on February 4, 2020. The Plan has paid for one unit of CPT 73720. The records do not support than a second MRI was provided on this date of service to support an additional unit of CPT 73720. Based on this information, we decided that Medicare rules for coverage of an additional unit of CPT 73720 have not been met.Therefore, we decided that the Plan does not have to pay forthe additional unit of CPT 73720 provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab tests provided on September 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab tests. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says these services were not urgent in nature.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 onlyin 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 forlab tests provided on September 12, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist services. You say that you would like approval for these services.The Plan denied your request. The Plan says there are in-network providers and facilities available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe DME provided to the enrollee on June 21, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the claim must be denied due to lack of supporting information in the medical records to support the codes billed. The Plan states there is no claim in the member history from the prescribing provider in the last 6 months prior to the date of the service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met.Therefore, we decided that the Plan does not have to pay forthe DME provided to the enrollee on June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CardioMEMS system for the enrollee.You asked the Plan to pre-approvethe system. You say that this is medically necessary.The Plan denied your request. The Plan says for this to be covered, the records must show a Medicare-approved clinical trial for measuring pulmonary artery pressure and heart rate.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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on dataobtained from a CardioMEMSdevice has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore,the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 system have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CardioMEMS system for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Supreme Comprehensive Pharmacogenomic Panel for the enrollee.
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the medical literature shows that better evidence is required to support large gene panels for pharmacogenomic testing.
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 panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence to support that the requested service is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve the Supreme Comprehensive Pharmacogenomic Panel for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProlia (J0897) for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy guidelines were not followed.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have osteoporosis. A request has been made for Prolia to treat the osteoporosis. The health plan requires that zoledronic acid be used first. There is no evidence that the enrollee is allergic to or intolerant of zoledronic acid. There is no evidence that the enrollee has tried and not responded to zoledronic acid. There is no documentation as to why zoledronic acid would not be expected to be safe and effective for the enrollee. Therefore, the requested Prolia is not shown to be currently medically necessary and reasonable. 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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProlia (J0897) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are not getting the rehab you need.The Plan denied your request. The Plan says the services are not medically necessary.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 medically necessary. Our physician reviewer found the submitted records show that you had a fall on July 9, 2020 and fractured your left femur. You underwent surgical repair on July 11, 2020. You need assistance with bed mobility, ambulation, toileting, and clothing management. You do not have complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRevlimid.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Revlimid.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.