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

We decided that the Plan does not have to pay for the Foundation One Liquid Dx testing rendered on September 29, 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 services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has malignant neoplasm of the prostate. The documentation does not support that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer, has not been previously tested with the same test using NGS for the same cancer genetic content, and has decided to seek further cancer treatment such as therapeutic chemotherapy. The testing was therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Foundation One Liquid Dx testing rendered on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of a lost or broken retainer (D8703) provided on November 9, 2020.

You asked the Plan to pay for the replacement of a lost or broken retainer. You say that this retainer should be covered because it had been pre-approved by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that they are not responsible for any misinformation you may have been given by an out-of-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the replacement of a lost or broken retainer (D8703) provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT).

You asked the Plan to pre-approve stereotactic body radiotherapy (SBRT). You say that the requested stereotactic body radiotherapy (SBRT) is medically necessary. The Plan denied your request. The Plan says that the requested stereotactic body radiotherapy (SBRT) is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 stereotactic body radiotherapy (SBRT). Our reviewer says that the requested stereotactic body radiotherapy (SBRT) is medically necessary. Our physician reviewer found arguably SBRT is more cost-effective (which would benefit the insurer), and perhaps equivalent or superior to conventionally fractionated IMRT/IGRT, though for high-risk disease, is still somewhat controversial. Nevertheless, based upon NCCN guidelines, SBRT with ADT would be "furnished in accordance with accepted standards of medical practice." Therefore, the requested SBRT is medically reasonable and necessary 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 stereotactic body radiotherapy (SBRT) have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a fitting of spectacles (92341) provided on December 15, 2020.

You asked the Plan to pay for the spectacle fitting. You say that this service was provided at the nursing facility where the enrollee resided at the time of service. The facility chooses providers to meet patient's needs. The Plan denied your request. The Plan says the provider in question is not in the Plan's network and the nursing facility where the enrollee resides is a non-participating facility.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. This service is not covered by Medicare and is not listed as a routine vision service that is covered by the Plan. The service was also not received from the Plan's specified vision provider. Based on this information, we decided that the Plan's rules for coverage of the spectacle fitting have not been met. Therefore, we decided that the Plan does not have to pay for a fitting of spectacles (92341) provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on August 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code remains 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. We find that HCPCS G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 (HCPCS G0482) provided to the enrollee on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an implant (D6010 x 4), and a custom abutment (D6057 x 4).

You asked the Plan to pre-approve the dental services. You say that you do not have a bridge or jaw bone on the bottom for your dentures to sit on. You also say that you cannot keep your dentures in place. The Plan denied your request. The Plan says implant related services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of an implant (D6010 x 4), and a custom abutment (D6057 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper extremity addition, test socket, wrist disarticulation or below elbow (L6680) addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert (L6697) addition to lower extremity, below knee (L5637).
You asked the Plan to pre-approve the prosthesis components. You say that you believe that the extension on your thumb will help you with basic activities of daily living that you cannot do at this time. The Plan denied your request. The Plan says the requested components L6680 is for a wrist disarticulation or a below elbow amputation. L6697 is for below elbow/above elbow amputation. L5637 is for a below the knee amputation. These levels are not consistent with the level of the partial hand.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The use of L-codes with specific amputation levels proximal to partial hand level would be considered incorrect coding. The enrollee does not have a below knee amputation, therefore L5637 cannot be covered. Based on this information, we decided that Medicare rules for coverage of the prosthesis components have not been met. Therefore, we decided that the Plan does not have to pre-approve upper extremity addition, test socket, wrist disarticulation or below elbow (L6680) addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert (L6697) addition to lower extremity, below knee (L5637).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen system and supplies.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the enrollee is not in a clinical trial.
The Plan must follow Medicare rules. The rules say that the home use of oxygen to treat cluster headaches is
covered by Medicare when part of an approved clinical study.
We looked at the file and Medicare rules. The file shows that the requested home oxygen is not for use with a
prospective clinical study. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable
oxygen system and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient mental health care provided from
April 15, 2021, forward.

You asked the Plan to pre-approve the acute inpatient mental health care. You say that inpatient mental health
care was medically necessary and reasonable. The Plan denied your request. The Plan says this patient did not
meet the level of care criteria for an acute inpatient psychiatric hospitalization but could have been treated in a
lesser restrictive setting as there were no records presented in this case for the dates in question.

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 the acute inpatient mental health care.
Our reviewer says that the inpatient mental health care was not medically reasonable and necessary after April
14, 2021. Our physician reviewer found this 82-year-old male was admitted to the acute inpatient psychiatric
hospitalization on April 7, 2021, with Major Depressive Disorder, Single Episode, Severe without Psychotic
Features. This enrollee did not require inpatient mental health treatment beyond the dates in question as he was
not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not
appear that active treatment was taking place beyond the date in question. It did not appear that the services for
the dates in question were reasonably expected or medically necessary to improve the patient's condition or for
the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon
review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental
health treatment beyond the date in question of April 15, 2021, forward and could have been treated in a lesser
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations,
delusions and was not showing any behaviors or aggression being cooperative and compliant while not
showing any acute threats to safety.

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 acute inpatient mental health care have not been met. Therefore, we decided
that the Plan does not have to pre-approve the acute inpatient mental health care provided from April 15, 2021,
forward.
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 care is medically necessary for the enrollee's condition. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 a 79-year-old female who was admitted to the acute care hospital. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 18, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond March 25, 2021.

You asked the Plan to pre-approve these services. You say that the enrollee needs more therapy. The Plan denied your request. The Plan says the continued services are 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and has stable vital signs. She has received physical and occupational therapy in the SNF and needs assistance with functional mobility, including walking 25 feet with a rolling walker. She requires varied levels of assistance with activities of daily living. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan.
You asked the Plan to pre-approve Rocklatan. You say that the enrollee has been on Rocklatan since 2019 with no complications. You also say that you would like to keep the enrollee on the same course of treatment. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rocklatan.
Benefits for Rocklatan may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 21, 2020.

You asked the Plan to pay for the laboratory services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says cardiovascular risk assessment testing is not covered by Medicare.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The test at issue in this appeal were requested for cardiovascular screening purposes. Medicare does not cover these codes for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 10, 2020.

You asked the Plan to pay for the dental service. You say that your old dentist retired. You say that it is very difficult to find a good dentist. You also say that you did not have any dental claims in 2020. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and the services is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on May 3, 2018, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section.

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 health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office consultation (99244) provided on September 11, 2020.

You asked the Plan to pay for the office consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99244 has a status indicator of I and is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99244 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99244 has a status indicator of I. This means that CPT code 99244 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the office consultation have not been met. Therefore, we decided that the Plan does not have to pay for the office consultation (99244) provided on September 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on December 21, 2020.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with 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 $200 copayment for outpatient surgery/in-network/outpatient hospital surgery services.

You have been asked to pay a $200 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital surgery 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 for an outpatient surgery provided by a participating provider on December 21, 2020.