Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on July 8, 2020.
You asked the Plan to pay for the occupational therapy services. You say that the medical records prove the
medical necessity for the services provided. You say that the claim should be reprocessed for payment. 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 occupational 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 services provided on this date did not require
the skilled services of an occupational therapist.
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 occupational therapy services have not been met. Therefore, we decided that
the Plan does not have to pay for occupational therapy services provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020.
You asked the Plan to pay for the hereditary cardio screen. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Tier 2 genetic tests are unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management and will be denied as not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the hereditary cardio screen, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from December 23, 2019, to December 24, 2019.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the requested inpatient care is considered post-stabilization care. Our physician reviewer found that as of 10:01 a.m. on December 23, 2019, the enrollee was stable for transfer to a Plan facility. There was no documentation provided necessitating continued post-stabilization care services at the non-Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from December 23, 2019, to December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cardiovascular risk assessment panel provided on April 14, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The requested risk assessment panel is non-covered per L36523. 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 forthe cardiovascular risk assessment panel provided on April 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on December 7,
2019, through December 9, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I
which is not valid for Medicare purposes.
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 S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9500 has a status indicator of I. This means that CPT code S9500 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500)
provided on December 7, 2019, through December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided on January 19, 2020.You asked the Plan to pay forgenetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing does not meet the Medicare criteria for coverage.The Plan follows Medicare rules. Medicare rules state that, for date of service January 19, 2020, Guardant360 testing is only covered when the clinical criteria listed above have been met. 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 genetic testing. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee had a diagnosis of stage IV metastatic squamous cell carcinoma of themiddle lobe, bronchus, or lung. PD-L1 expression was positive. The enrollee was not an untreated patient at the time of diagnosis. There was no indication that EGFR single nucleotide variants (SNVs), insertions and deletions (indels), rearrangement in ALKand ROS1, or SNVs for BRAF were not available, and that tissue-based CGP was infeasible. There was no indication that the enrollee had progression on treatment. Therefore, this testing was 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 genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forGuardant360 testing provided on January 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe durable medical equipment to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe durable medical equipment. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the durable medical equipment you are requesting.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 ofarea 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-approvethe durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for surgical services provided to the enrollee on April 3, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that the diagnosis code is not valid.
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 substantiated their denial. M48.06 is a valid diagnosis code that
represents "spinal stenosis, lumbar region." The progress record included in the case file shows this as both a
pre-operative and post-operative diagnosis. Therefore, we decided that the Plan has to pay for surgical services
provided to the enrollee on April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic testing provided on May 16, 2020.
You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for these services is correct, because these tests are
not covered by Medicare under the circumstances.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
There is no documentation in the record of a concern for a specific drug metabolism issue for which this testing
was ordered. This was provided in the absence of signs/symptoms of a medical condition. This means it is
screening in nature which is not covered by Medicare. Therefore, we decided that the Plan does not have to pay
for pharmacogenomic testing provided on May 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography with computer-aided detection you had at an outpatient hospital facility on June 2, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that if you had know this test wouldn't be covered at 100% you wouldn't have had it. You said that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $110 copayment for x-rays in an outpatient hospital facility. You have been asked to pay a $110 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the x-rays in an outpatient hospital facility 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 diagnostic mammography with computer-aided detection you had at an outpatient hospital facility on June 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray (71045) provided on May 18, 2020.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration because the x-ray was performed since the required admission test was refused by the member.The Plan denied your request. The Plan says this service is not appropriate for the diagnosis code billed.The Plan must follow Medicare rules. Medicare rules say that when the original treatment plan is not carried out, sequence as the principal diagnosis the condition.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Specifically, this claim was not billed with the member's condition as the primary diagnosis code.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71045) provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided on July 10, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 thePlan does not have to pay forout of network physician services provided on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive stool profile panel testing provided on March 31, 2020.You asked the Plan to pay forlab tests. You say that these tests are covered by Medicare.The Plan denied your request. The Plan says the denial of payment for these services is correct, because there is insufficient information to show the services were medically necessary for the enrollee's unique clinical scenario and Medicare does not cover these tests for screening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.There is no documentation of a specific concern for which these tests were ordered, nor that the results were requested to guide therapeutic decision-making. Medicare does not cover these tests for screening purposes.
Therefore, we decided that the Plan does not have to pay forcomprehensive stool profile panel testing provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 16, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for these services is correct, because the documentation submitted
does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The documentation submitted does not support that the sample for
this testing was taken in an independent laboratory setting; therefore, the billed Place of Service (POS) code 81
- indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan
does not have to pay for laboratory testing provided on January 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer saysthat daily skilled services are not necessary. Our physician reviewer found the you were admitted to the hospital on November 13, 2020,after a fall with a resulting femur fracture. You received oral medications and had stable vital signs. You received physical and occupational therapy in the hospital and need maximal assist with functional mobility, including walking to 10 feet with a rolling walker. You have no skilled nursing needs. You have skilled therapy needs but does not require skilled therapy on adaily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admissioncare.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for panel testing provided on March 12, 2020. You asked the Plan to pay for lab tests. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these labs are not medically reasonable or necessary and no rationale for this testing was included. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The documentation submitted does not show a specific diagnostic rationale for which this testing was ordered or that the results were requested to guide therapeutic decision-making. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for panel testing provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on March 27, 2020, April 29, 2020, and May 13, 2020 by an out of network provider.You asked the Plan to pay forthe physician services. You say that you were told this doctor was a participating physician.The Plan denied your request. The Plan says the services with the out-of-network physician were not urgent, emergent or approved in advance.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 servicesat 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 forthe physician services provided on March 27, 2020, April 29, 2020, and May 13, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 26,
2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says based on the clinical information provided regarding the prostate needle biopsy; section
"D" did not reveal atypical small acinar proliferation, suspicious for carcinoma. Therefore, the services billed
cannot be confirmed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and the records provided must support the
services billed. In this case, the records provided do not show the enrollee met the required coverage criteria
when the services were provided. Medicare rules for coverage of this testing have not been met. Therefore, we
decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVascepa.You asked the Plan to pre-approveVascepa. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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-approveVascepa.Benefits for Vascepamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from March 5, 2020, to May 14, 2020.You asked the Plan to pay forhome infusion therapy. You say that this should be covered.The Plan denied your request. The Plan says this is not a payable code.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 S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from March 5, 2020, to May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on March 10, 2020.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this test is correct, because the custom panel
document for this testing was not signed and dated by the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on March 10, 2020.