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

We decided that the Plan does not have to pre-approve Palonosetron for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says in order for this service to be medically necessary, you must be taking certain intravenous medications that cause nausea and vomiting.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found in this case the enrollee will not be receiving chemotherapy with a moderate or high antiemetic risk. The review has determined that the documentation does not support that the Palonosetron is medically reasonable or necessary for the enrollee. The documentation does not support that the Palonosetron is safe and effective for the enrollee. Palonosetron is a second-generation 5HT3-antagonist, and is already available in many countries for use in chemotherapy-induced nausea and vomiting. It is marketed under license by various companies, mostly under the brand name Aloxi (although it is also marketed as Onicit and Paloxi). In the United States, the product was approved as an oral capsule in August 2008, but has been available as an intravenous injection since 2003.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 Plan does not have to pre-approve Palonosetron for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services received on February 4, 2020.You asked the Plan to waive the copayment forthe services. You say that the PCP ordered some diagnostic tests, and you got them done in the same building as the PCP.The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.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$10 copayment for laboratory services. You have been asked to pay a $10 copayment for the services. The services fall within the laboratory 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 forlaboratory services received on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a laparoscopic appendectomy.You asked the Plan to pre-approve the referral. You say that this is medically necessary for continuation of care.The Plan denied your request. The Plan says there are several in-network surgeons that can assist the enrollee with their needs.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 a referral to an out-of-network provider for a laparoscopic appendectomy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating facility on March 10, 2020.You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you do not feel like you should be liable for this copayment. 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 $275 copayment for outpatient surgery/in-network/ambulatory surgical center. You have been asked to pay a $275 copayment for a diagnostic colonoscopy. When a colonoscopy is provided due to a medical complaint it is considered diagnostic; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network/ambulatory surgical center 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 a diagnostic colonoscopy provided by a participating facility on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe allograft rendered on August 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 20930 is not separately payable.The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.We looked at the file and Medicare rules. The services at issue are an allograft billed with code 20930. This code has a status indicator of B and no separate Medicare payment.Therefore, we decided that the Plan does not have to pay forthe allograft rendered on August 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Levocarnitine injection.
You asked the Plan to pre-approve the Levocarnitine injection. You say that you would like reconsideration because this injection is medically necessary. The Plan denied your request. The Plan says there was no clinical documentation submitted to support the medical necessity of the Levocarnitine injection
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 Levocarnitine injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested Levocarnitine injection. 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 Levocarnitine injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Levocarnitine injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on September 24, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab 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 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 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 lab tests provided on September 24, 2019 by an
out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on available records, the documentation does not support that you need daily skilled nursing or daily skilled therapy services. The records do not show any complex health situations that require daily care in a SNF setting. Medicare coverage criteria for SNF services are not met. 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that you would like reconsideration because this service
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy
exception 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 Hyalgan. Our reviewer says that There
is no evidence that the enrollee is allergic to or intolerant of the Plan's preferred forms of hyaluronic acid. Our
physician reviewer found there is no evidence that the enrollee has tried and not responded to these other forms
of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would
not be expected to be safe and effective for the enrollee. Therefore, the requested Hyalgan 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan (J7321).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on February 19,
2020. You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because
you do not believe you should be responsible for these charges. The Plan denied your request. The Plan says
this provider does not meet the license criteria per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that Part B covers mental health services and visits
with specific types of health professionals.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy services have not been met. Specifically, this provider is licensed as a
Professional Counselor and does not meet Medicare license criteria for mental health services. Additionally,
this provider is not a member of the Plan's network. Therefore, we decided that the Plan does not have to pay
for psychotherapy services (90834) provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203), manual therapy techniques (97140) and therapeutic exercises (97110) provided on February 25, 2020 through March 10, 2020.You asked the Plan to pay for the office visit, manual therapy techniques and therapeutic exercises.. You say that you would like reconsideration because chiropractic services are covered benefits per your EOC.The Plan denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for an office visit (99203), manual therapy techniques (97140) and therapeutic exercises (97110) provided on February 25, 2020 through March 10, 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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you required maximum assistance for bed mobility and transfers. You were unable to ambulate. You required moderate assistance with upper body dressing and bathing. You were dependent with lower body dressing and toileting. The documentation does not support that you require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need for acute rehab nursing care. While you may benefit from further physical and occupational therapy, you do not require an intensive therapy program. Your care needs can be met at a lower level of care. 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management provided on November 8, 2019.
You asked the Plan to pay for the hospital discharge day management. The Plan denied your request. The Plan says the member was enrolled in a federal hospice program during the time services were rendered. Per Medicare guidelines, the member's services should be billed under Original Medicare.
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 hospital discharge day management provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveBotox.You asked the Plan to pre-approveBotox. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that Botox is covered for certain indications.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 Botox. Our reviewer says that the documentation supports that the requested Botox is medically reasonable and necessary. Our physician reviewer found the enrollee has evidence of bilateral Raynaud's syndrome. The enrollee has a history of distal finger necrosis and is limited functionally by her condition. While the LCD does not allow for Botox injection for Raynaud's syndrome, other references state that Raynaud phenomenon, classified as primary idiopathic or secondary disease, involves vasospastic episodes affecting cutaneous arterial inflow in localized areas including fingers and toes leading to pain, ischemia, ulceration, and potential amputation.108 The efficacy of pharmacologic treatment for severe disease is variable, with some patients requiring sympathectomy for symptomatic relief. Botulinum toxin has been found to be an effective treatment option through an unclear mechanism, which may be related to its increase in vasodilation through sympathetic blockade. A recent systematic review found a wide dosage range in prior reports from 12 to 300 U per hand primarily into digital neurovascular bundles and/or superficial palmar arch, and they largely showed improvements relating to digital temperature; pain; Disabilities of the Arm, Shoulder and Hand score; and ulcer healing. Therefore, there is evidence of efficacy with Botox treatment for an enrollee like this one. Although the request does not satisfy the above LCD, there is enough evidence to support Botox treatment as another conservative treatment option, prior to surgical intervention, especially considering the history of distal finger necrosis. Therefore, the enrollee does 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 Botox have been met.Therefore, we decided that the Plan has to pre-approveBotox.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says 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 forthe drug testing rendered on April 3, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 27, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on March 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on March 13, 2020.