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

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a participating provider on February 23, 2021.
You asked the Plan to waive the copayment for diagnostic radiology services. You say that you don't know if this procedure was even done. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $325 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay a $325 copayment for a PET scan. The correct copayment has been applied to the services that were provided. Diagnostic radiology services falls within the outpatient diagnostic tests/diagnostic
radiology 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 copayment for diagnostic radiology services provided by a participating provider on February 23, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. 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. Medicare rules say that oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).
You asked the Plan to pre-approve the power seat elevation feature. You say that you need the power seat elevation feature for your wheelchair so you can reach items. The Plan denied your request. The Plan says power seat elevation features are not primarily medical in nature and is not covered.
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. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy.
You asked the Plan to pre-approve Yervoy. 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 Yervoy. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Ipilimumab is not Food and Drug Administration (FDA) approved for the treatment of prostate cancer. Use is not supported by major drug compendia or the medical literature. The service is not reasonable or 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 Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging, spinal canal and contents (72148) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the diagnostic service. You say that you are experiencing sharp pains in your back that radiates into your left leg. Your doctor requesting the exam needs the information in order to find out how to move forward with the enrollee's treatment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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-approve magnetic resonance imaging, spinal canal and contents (72148) to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on September 21, 2020.
You asked the Plan to pay for the laboratory testing. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on September 21, 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 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404) provided January 30, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease.
We looked at the file and Medicare rules. The cardiovascular risk assessment tests are not covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404) provided January 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to the LTACH.
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 there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 admission to a LTACH.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test.
You asked the Plan to pre-approve an OmniSeq Insight Panel test. You say that OmniSeq testing was ordered to assist in determining the most appropriate treatment pathway. You say that the enrollee meets the coverage criteria and demonstrates medical necessity for the testing. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage because the OmniSeq Insight Panel test is not likely to impact therapeutic decision making in the clinical management and is not considered medically necessary.
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures may be eligible for coverage when the results of the testing directly impact treatment or management of the Medicare beneficiary. 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 an OmniSeq Insight Panel test. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a new diagnosis of invasive adenocarcinoma of the lung. It is documented that the enrollee will have to be evaluated to determine if she is strong enough to tolerate chemo and immunotherapy. OmniSeq is a comprehensive genomic and immune profiling assay for solid tumors which interrogates the exonic coding region of 523 genes by next generation sequencing. The available documentation does not demonstrate that OmniSeq Insight Panel testing will directly impact treatment or management of the enrollee in this case. Additionally, it has not been shown that the number of genes in the OmniSeq Insight Panel is reasonable and necessary to obtain the necessary information for therapeutic decision making.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OmniSeq Insight Panel test have not been met. Therefore, we decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. 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.
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 Durolane. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Orthovisc 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that your pain levels are 8/10 on most days. The Plan denied your request. The Plan says this is being requested for outdoor use.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation is not specific on what MRADLs are affected in the home. It is not clear why you cannot use a walker or a manual wheelchair, as you have 5/5 bilateral upper extremity strength and normal musculoskeletal range of motion. The nurse practitioner notes on 3/21 indicates you use a walking boot and have no walking problems on the review of systems. It is not clear if this scooter will significantly improve or primarily be used for MRADLs in the home. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says at this time, there is a lack of literature with true head-to-head comparisons to other standard treatments.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is considered experimental/ investigational and is the subject of ongoing clinical trials to assess its role in the treatment of knee osteoarthritis. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for a POV have not been met.
The Plan follows Medicare rules. Medicare rules say that a POV will not be covered if the record does not document that the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV. The file does not contain records of a home evaluation to document that your home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the requested POV. This means that Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7140), and drugs or medicaments dispensed
in the office for home use (D9630) provided on April 5, 2021.
You asked the Plan to pay for an extraction, and drugs or medicaments dispensed in the office for home use.
You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are
not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
extraction (D7140), and drugs or medicaments dispensed in the office for home use (D9630) provided on April
5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Free Style Libre CGM. You say that the enrollee has diabetes mellitus and it has been occurring for years. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not uses insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Free Style Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable battery powered oxygen concentrator.
You asked the Plan to pre-approve a portable battery powered oxygen concentrator. You say that the enrollee needs a portable oxygen concentrator. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered. Based on this information, we decided that Medicare rules for coverage of a portable battery powered oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable battery powered oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided during a gastrointestinal procedure on August 5, 2020, with 176 minutes reported.

You asked the Plan to pay for the anesthesia services as billed. You say that the records support payment for these services. The Plan denied your request. The Plan says no anesthesia report was submitted to verify the time reported.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

In this case, 176 minutes of anesthesia care were reported; however, no anesthesia note was submitted for review. Without confirmation of the time anesthesia was started and stopped, payment cannot be approved. Based on this information, we decided that Medicare rules for coverage of the anesthesia services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided during a gastrointestinal procedure on August 5, 2020, with 176 minutes reported.