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

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any documented skilled therapy or skilled nursing 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 SNF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 10, 2021, to February 13, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says you needed care in a hospital, but the care could be given at a different level.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that a lower level of care would have sufficed, based on the records. There was no
expectation that the patient would require hospital services for at least 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided February 10, 2021, to February 13,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near his baseline. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 71-year-old male was being treated for low back pain. He presented with a significant amount of lower back pain still. He states that it is severe and is interfering with his everyday life. He states that the pain is all across his lower back, and not worse on a specific side. He notes a history of L4-5 endoscopic discectomy and foraminoplasty in August, 2020 (with at least 50-75% better with regard to his left lower extremity and about 80% pain relief in the right lower extremity.) However, detailed documentation is not evident regarding a trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to the considered procedure. Furthermore, detailed documentation is not evident regarding Modic changes noted on the official magnetic resonance imaging (MRI) report/reading. Additionally, multiple other plausible pain generators (including at the lumbosacral spine) are evident. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Intracept procedure at L3, L4, and L5 is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 13, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should be charged a $0 copayment for the virtual visit. The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment for specialty care physician. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $35 copayment for the specialist office visit.

You have been asked to pay a $34.89 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were charged for an office visit.

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 specialist office visit provided on January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (J3590).
You asked the Plan to pre-approve Aduhelm. You say that Aduhelm is medically necessary. The Plan denied your request. The Plan says this drug is experimental and is non-covered.
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 Aduhelm. Our reviewer says that Aduhelm is not medically necessary. Our physician reviewer found the documentation in the medical record is insufficient to support the diagnosis of Alzheimer's disease. The documentation does not support that there has been a significant steadily progressive cognitive decline from a previous level of performance, or that the enrollee has cognitive deficits that interfere with her activities of daily living. In addition, the MRI imaging in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J3590).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the arthrocentesis provided on January 14, 2021.
You asked the Plan to reduce the copayment for the arthrocentesis. You say that this was not surgery, but an office visit. You say the visit was not at an ambulatory surgical center. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $15 copayment for Medicare-covered outpatient stay. The Plan says you must pay a $100 copayment for the arthrocentesis. Based on the Plan contract, however, you cannot be asked to pay more than a $15 copayment for the arthrocentesis. The record shows the provider billed with location code 22 which is an outpatient hospital. Please note, arthrocentesis is considered a surgical procedure. Therefore, we decided that the Plan has to reduce the copayment for the arthrocentesis provided on January 14, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on November 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 drug testing provided on November 18, 2020 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 office visit (99214) provided on August 20, 2020, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that you are a contracted provider. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network 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 had network providers available who could have provided 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 (99214) provided on August 20, 2020, by an out-of-network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 14, 2021.
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 testing 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 shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for 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 January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency ablation of benign, symptomatic thyroid nodule.
You asked the Plan to pre-approve the radiofrequency ablation services. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational for the indication of thyroid nodules.
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 radiofrequency ablation services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 71-year-old woman with a Nontoxic single thyroid nodule. The plan denied coverage of radiofrequency ablation in this case, stating that this treatment is considered to be experimental and investigational because of insufficient evidence of its long-term effectiveness. It has not been firmly established that radiofrequency ablation is a valid alternative to conventional treatments for nontoxic thyroid nodules.
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 radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablation of benign, symptomatic thyroid nodule
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was intubated as of August 15, 2021, and sedated and not participating in physical therapy or occupation therapy. The enrollee is not ready for inpatient rehab at any setting and needs to be evaluated and attain medical stability for a re-referral for an appropriate setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Specifically, the enrollee is not medically stable and needs further evaluation. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen.

You asked the Plan to pre-approve Epogen. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug 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 Epogen. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has anemia in chronic kidney disease. The documentation does not support that the enrollee has tried and failed Retacrit. The documentation does not support any indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric 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 inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care. Our reviewer
says that the services are not medically necessary. Our physician reviewer found based upon review of the
records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment
beyond the date in question of August 10, 2021, forward and could have been treated in a lesser restrictive
setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were
not showing any aggressive behaviors. You were being cooperative and compliant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment (E0431, E0424, E0600) provided September 2, 2020.
You asked the Plan to pay for the oxygen equipment. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery. The record did not include an itemized shipping or billing receipt. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for oxygen equipment (E0431, E0424, E0600) provided September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl (J0896).
You asked the Plan to pre-approve Reblozyl. You say that the drug is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Reblozyl in the absence of ring sideroblasts have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Reblozyl. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the clinical value and effectiveness of Reblozyl in the absence of ring sideroblasts have not been demonstrated in the peer-reviewed literature. The requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journals. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl (J0896).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for a splint application (29125) provided February 15, 2021.
You asked the Plan to pay for the splint application. You say that the service was medically necessary. The Plan denied your request. The Plan says this service was incidental to another service billed and is not separately payable.
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, we have confirmed that code 29125 has a column I/column II relationship with code 20605 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a splint application (29125) provided February 15, 2021.