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

We decided that the Plan does not have to pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on July 1, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the recordsdo not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of the denied codes is: CPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479HCPCS G0482:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records contain a signed and dated order for drug testing but this order does not contain any identifying patient information. There are no medical records or summary documentation of the patient's medical history. There is no report of the ordered drug testing from 7/1/2020. The records do not support the coding of CPT 80307 and HCPCS G0482.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 pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on July 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for anterior instrumentation (22845) provided on January 21, 2020.You asked the Plan to pay forthe anterior instrumentation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 22845 is a column II procedure to the more comprehensive column I procedure.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 asked our coder 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 anterior instrumentation. Our reviewer says that CPT code 22845 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to support billed 22845 as an independent procedure from primary procedure 22853 so this service cannot be verified as eligible for separate reimbursement consideration.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anterior instrumentation have not been met.Therefore, we decided that the Plan does not have to pay foranterior instrumentation (22845) provided on January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scans provided on December 12,
2019.
You asked the Plan to waive the copayment for the CT scans. You say that the office is an in-network provider.
You say that insurance should have paid the copayment. The Plan denied your request. The Plan says the
copayment applied 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 $270
copayment for all other diagnostic and nuclear medicine radiological services. If multiple tests of the same type
(for example, CT scan of the head and CT scan of the chest) are performed in the same day, one copayment
will apply.
You have been asked to pay a $270 copayment for the CT scans. The CT scans falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The records show that you have been
asked to pay the in-network copayment. 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 CT
scans provided on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Reblozyl.You asked the Plan to pre-approveReblozyl. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the documentation indicates that no ring sideroblasts are present and therefore alternative treatment options should be considered.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 Reblozyl. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Reblozyl. Our physician reviewer found luspatercept (Reblozyl) is approved by the Food & Drug Administration (FDA) for the treatment of anemia associated with myelodysplastic syndrome (MDS) with ring sideroblasts, or MDS with ring sideroblasts and thrombocytosis. The drug is most effective in the setting of MDS with ring sideroblasts. The documentation does not support that Reblozyl is medically reasonable and necessary for the enrollee in this case, as there is no documentation of the presence of ring sideroblasts. The documentation does not support that Reblozyl is safe andeffective 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 Reblozyl have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Reblozyl
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but
based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation
therapy program.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the soft tissue of the neck. You asked the Plan to pre-approve a CT scan of the soft tissue of the neck. You say that the requested CT scan of the soft tissue of the neck is medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the soft tissue of the neck is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT scan of the soft tissue of the neck. Our reviewer says that the requested CT scan of the soft tissue of the neck is medically necessary. Our physician reviewer found the enrollee is with a history of head and neck cancer in 2014. Per NCCN guidelines for head and neck cancer, routine annual imaging may be indicated to visualize areas inaccessible to routine clinical exams. In this case the requested CT scan is medically reasonable and necessary 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 a CT scan of the soft tissue of the neck have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the soft tissue of the neck.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of care for chemotherapy with an out-of-network provider.
You asked the Plan to pre-approve chemotherapy. You say that you are requesting continuation of therapy. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 chemotherapy. Our reviewer says that the enrollee does not meet the Medicare criteria for continuity of care with the requested out-of-network provider. Our physician reviewer found the enrollee is on a standard chemotherapy regimen that can be given at any cancer center. There is nothing unique about the enrollee's condition that would make it medically necessary for her to continue care with an out-of-network provider. The Plan has shown that they have in-network providers who have the qualifications and expertise necessary to meet the standards of care required
for treatment of the enrollee's condition. The enrollee is on palliative chemotherapy and can be safely transitioned to an in-network provider between cycles. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chemotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of care for chemotherapy with an out-of-network provider.
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 IRF services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 the enrollee is not shown to require, or to be able to currently perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, electronic connection, and expandable controller harness.
You asked the Plan to pre-approve an expandable controller, electronic connection, and expandable controller harness. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that expandable controllers, electronic connections, and expandable controller harnesses are only 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 an expandable controller, electronic connection, and expandable controller harness. Our reviewer says that the documentation does not support that the requested items were medically reasonable or necessary. Our physician reviewer found the documentation shows that your strength appears to be sufficient to control the power options with their separate switches already included with the approval of these power options. The documentation shows that you have +3/5 right and left upper extremity strength. This upper limb strength and function are expected to be adequate for you to be able to control the power options using your own switches, which are included in the allowance of these power options. Therefore, you do not meet criteria for the requested items. 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 expandable controller, electronic connection, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, electronic connection, and expandable controller harness.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography 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 that there is no medical documentation provided to support the medical necessity for the requested service.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has increased cardiac risk, chest symptoms and dyspnea with a normal Holter, normal LVEF on nuclear stress test and no provokable ischemia. In this circumstance although ischemia and LV dysfunction have been ruled out as a cause of the patient's symptoms, other possibilities remain such as pulmonary hypertension, pericardial disease and/or occult valvular disease. These would all be appropriately evaluated by echocardiography. Therefore the records due support that an echocardiogram is reasonable and appropriate. 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 been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiography for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve PT visits to be provided by an OON provider. You say that you are comfortable with your provider and do not want to have to change. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.
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 physical therapy (PT) visits to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device (E0601).
You asked the Plan to pre-approve continued use of a CPAP device.. You say that the enrollee needs this device. The Plan denied your request. The Plan says the enrollee has not been compliant with therapy.
The Plan must follow Medicare rules. Medicare rules say that continued use of a PAP device requires objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner, with adherence defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. The record does not show that the enrollee has used the CPAP device for at least 4 hours on 70% of nights. Based on this information, we decided that Medicare rules for coverage
of continued use of a CPAP device. have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (71046, Q0092, R0070) provided on
December 3, 2019.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network
providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the radiology services (71046, Q0092, R0070)
provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for care management services (99484) provided on October 30, 2019.
You asked the Plan to pay for the care management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99484 is care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team. We asked our coder 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 care management services. Our reviewer says that CPT code 99484 does not meet criteria for billing or reimbursement consideration. Our reviewer found medical records submitted do not indicate that care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team was performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the care management services have not been met. Therefore, we decided that the Plan does not have to pay for care management services (99484) provided on October 30, 2019.