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

We decided that the Plan does not have to pre-approve Xgeva (denosumab) treatments.You asked the Plan to pre-approve the Xgeva. You say that the enrollee should be allowed to use Xgeva to treat the hypercalcemia of malignancy.The Plan denied your request. The Plan says there is no evidence that the plan's preferred drugs would not be effective in this case.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 the Xgeva. Our reviewer says that the requested drug is not considered reasonable and necessary based on the step therapy rules. Our physician reviewer found this review relates to a request for Xgeva to treat hypercalcemia ofmalignancy in a 61 year old man with non-Hodgkin's lymphoma. At the time of the office visit on 3/23/20 his calcium was 10.5. No albumin level was included in the submitted information. The submitted information states the enrollee has not been treated with either Pamidronate or Zoledronic acid. The prior authorization form dated 3/25/20 indicates the enrollee has not had prior therapy, intolerance, or contraindication to intravenous bisphosphonate therapy nor has he had progression, intolerance or contraindication following treatment with the required drugs. Should he have recurrent hypercalcemia, the plan's required drugs would not be less effective or likely have more adverse effects than Xgeva. Zoledronic acid and Pamidronate are both indicated for the treatment of hypercalcemia of malignancy and the only labeled contraindications are hypersensitivity to them.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged hospitalization and close physician monitoring. The Plan denied your request. The Plan says the enrollee is medically stable and does not need ongoing treatment.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an ACH for strokes, which were initially thought to be embolic, but were ultimately determined to be vasculitic. The enrollee continues to receive her baseline hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eye surgery services provided by the Hospital from August 28, 2019 to August 29, 2019.
You asked the Plan to pay for eye surgery services. You say that the quote you received from this provider was less than half the cost of a provider in the United States, so you are requesting reimbursement for the amount the Plan would have paid to a provider within the United States. The Plan denied your request. The Plan says the denial of payment for these services is correct, because neither Medicare nor the Plan covers these services when obtained outside of the United States.
The Plan must follow Medicare rules. Medicare rules say that services furnished outside of the United States are not covered by Medicare except in certain specific circumstances. The Plan offers additional worldwide coverage that goes beyond Medicare's coverage; however, the Plan does not cover non-urgent or non-emergent services furnished outside of the United States. We looked at the file and Medicare rules. These services do not meet any of the specific circumstances in which Medicare covers services provided outside of the United States. These services also do not meet the Plan's criteria for supplemental worldwide coverage, because the need for service was foreseeable prior to leaving the United States and elected to receive these services in Turkey, therefore the services were not urgent or emergent in nature. Therefore, we decided that the Plan does not have to pay for eye surgery services provided by the Hospital from August 28, 2019 to August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 16, 2019.You asked the Plan to waive the copayment for the medical eye exam. You say that you only went to pick up a prescription for glasses and was told that there would be no charge to pick them up. The Plan denied your request. The Plan says you have been charged 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 each in-network Medicare-covered exam to treat an eye condition. You have been asked to pay a $35 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows the medical eye exam was for post-procedural aftercare, presence of other functional implant, disorders of refraction and accommodation, other corneal disorders, and visual disturbances.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 medical eye exam provided on October 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound rendered to enrollee on January 28, 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 76700 is not supported.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 76700 is ultrasound, abdominal, real time with image documentation; complete.We find that CPT code 76700 is not supported in the medical record. Specifically, the records do not indicate that a retroperitoneal ultrasound was performed. There is a more appropriate code for the services rendered. 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 ultrasound rendered to enrollee on January 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found ongoing care needs include respiratory support including BiPAP with oxygen supplementation, nebulizer treatments, surveillance laboratory studies, close fluid balance, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the guidelines for coverage have not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute care hospital with status epilepticus, they required intubation and levophed for a period. The enrollee is not more stable, was only requiring bipap at night, pressors were discontinued, and her diet was advancing appropriately. On March 25, 2020 the enrollee was deemed appropriate for discharge, which appears appropriate based on the documentation provided. There are no current acute care needs that would be better accommodated and covered via LTACH services to justify this request. The current documentation suggests the ability to transfer to a lower level of care soon to continue wound care, oral medication management, continued spirometry, and basic monitoring needs. Until then, continued acute care services at the current facility should suffice.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) provided on August 18, 2019.
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration as this claim denied as a duplicate in error. The Plan denied your request. The Plan says this is a duplicate of a charge considered on a previous claim.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Specifically, the information on this claim includes the same provider, group, beneficiary and date of service as a previously considered claim. The record does not indicate that this service was provided multiple times on the same date of service. Therefore, we decided that the Plan does not have to pay for an ultrasound (76770) provided on August 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from October 25, 2019 to October 27, 2019. You asked the Plan to waive the copayment foran ER visit. You say that you were told that you were admitted you would not owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $120 copayment for emergency care. The record shows that you received outpatient hospital services following an ER visit from October 25, 2019 to October 27, 2019. The ER copayment is only waived if you are admitted inpatient. Therefore, you are responsible to pay the $120 copayment. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that youhave 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 foran ER visit provided from October 25, 2019 to October 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung
Cancer Screening (G0297).
You asked the Plan to pre-approve the Lung Cancer Screening. You say that the service is medically necessary
due to your smoking history. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that LDCT Lung Cancer Screening is covered for
enrollees ages 55 to 77 with smoking history.
We looked at the file and Medicare rules. While the record shows a history of smoking, the enrollee no longer
meets the age requirements outlined in Medicare rules. Based on this information, we decided that Medicare
rules for coverage of the Lung Cancer Screening have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
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-of-network
provider on September 6, 2019.
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 September 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of coverage for skilled nursing facility (SNF) services after March 11, 2020.You asked the Plan to pre-approve coverage for SNF services after March 11, 2020. The Plan denied your request. The Plan says based on Medicare guidelines for SNF care, once the enrollee has reached the 100-day benefit limit then the enrollee is no longer eligible for skilled nursing care during this benefit period.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from December 3, 2019 through March 11, 2019.The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continuation of coverage for skilled nursing facility (SNF) services after March 11, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 24, 2019.
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 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 for the drug testing rendered to the enrollee on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for static progressive stretch knee device provided October 8, 2019 to November 8, 2019
You asked the Plan to pay for static progressive stretch knee device. You say that you received a prescription for this device for each knee to help increase her flexion. With use of the device as recommended the enrollee is expected to restore functional range of motion. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for static progressive stretch knee device provided October 8, 2019 to November 8, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services provided from April 8,
2018 to April 14, 2018.
You asked the Plan to pay for the direct skilled nursing services. The Plan denied your request. The Plan says
that the information received did not show that the enrollee had a skilled nursing need for nursing home visits.
The Plan also says the documentation did not show that the nursing visit was medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider must submit all documentation to
confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The record shows that no documentation was submitted to support
coverage of these services. Based on this information, we decided that Medicare rules for coverage of the direct
skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the
direct skilled nursing services provided from April 8, 2018 to April 14, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to the enrollee on September 4, 2019.
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 procedure code G0483 is not supported.
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 G0483 is definitive drug testing, 22 or more classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. 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 definitive drug testing rendered to the enrollee on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 24, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.
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 valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on October 28, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on October 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay fordrug testing services provided to the enrollee on October 24, 2019.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 the records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medicalrecords stating exactly tests were to be performed. 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 for drug testing services provided to the enrollee on October 24, 2019.