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

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 27, 2021.
You asked the Plan to pay for the laboratory services. You say that the enrollee should be eligible for the GeneSight Psychotropic (81479). The Plan denied your request. The Plan says GeneSight Psychotropic is not covered by Medicare.
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 laboratory services. Our physician reviewer found the review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 27, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Your medical conditions are stable. You do not have complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is
no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care.
Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an IRF.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 enrollee would benefit from intensive therapy
and medical management. The Plan denied your request. The Plan says the denial of authorization for IRF
service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine Sulfate ER for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Morphine Sulfate ER for
the enrollee.
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric care provided October 1, 2020, to October 30, 2020.
You asked the Plan to pay for the inpatient psychiatric care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the inpatient psychiatric care was not medically reasonable and necessary.
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 pay for the inpatient psychiatric care. Our reviewer says that the inpatient psychiatric care was not medically reasonable and necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. This patient was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 1, 2020, forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric care provided October 1, 2020, to October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you would benefit from rehab. The Plan denied your request. The Plan says that the records do not support the need for daily therapy in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre supplies.
You asked the Plan to pre-approve the Freestyle Libre supplies. You say that you would like reconsideration because the member has been using this continuous glucose monitor since 2019 and urgently requires refills. The Plan denied your request. The Plan says the member does not use insulin three times per day or use an insulin pump.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre supplies. Our reviewer says that the member does not meet Medicare coverage criteria for the Freestyle Libre supplies. Our physician reviewer found the records show that the member uses insulin twice per day.
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 Freestyle Libre supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre supplies
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the radiation therapy provided on July 13,
2020 or waive the copayment for the spine x-ray provided on April 25, 2021.
You asked the Plan to waive the cost share for the radiation therapy and the spine x-ray. You say that you do
not have access to a freestanding facility so your cost share should be less. The Plan denied your request. The
Plan says you were charged the coinsurance 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 $100
copayment for Outpatient Hospital Basic Radiological Services and 20% coinsurance for Outpatient Hospital
Services Radiation Therapy.
You have been asked to pay a $100 copayment for the x-ray and 20% coinsurance for the radiation therapy.
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 cost share for the radiation therapy provided on July 13, 2020 or waive the
copayment for the spine x-ray provided on April 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Xopenex HFA 45 mcg inhaler for the enrollee.
You asked the Plan to pre-approve the inhaler. You say that this is medically necessary. The Plan denied your request. The Plan says there is no Part D coverage.
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 a Xopenex HFA 45 mcg inhaler for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 13, 2021.
You asked the Plan to pay for the laboratory services. You say that the enrollee should be eligible for the Genesight Psychotropic (81479). The Plan denied your request. The Plan says GeneSight Psychotropic is not covered by Medicare.
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 laboratory services. Our physician reviewer found the review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 13,
2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 21, 2021.
You asked the Plan to pay for the laboratory services. You say that the enrollee should be eligible for the GeneSight Psychotropic (81479). The Plan denied your request. The Plan says GeneSight Psychotropic is not covered by Medicare.
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 laboratory services. Our physician reviewer found there was no specific clinical rationale for the requested GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 21, 2021. The medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital-to-hospital transfer.
You asked the Plan to pre-approve hospital transfer. You say that you can receive more adequate and proper medical treatment at the requested facility. The Plan denied your request. The Plan says the denial of authorization for a hospital transfer is correct, because you are receiving appropriate inpatient care and there are no services at the requested facility that are not available at the current facility.
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 hospital transfer. 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 documentation of additional services at the requested facility that are not available at the current facility. You remain critically ill and your medical needs are being met in the current acute setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hospital transfer have not been met. Therefore, we decided that the Plan does
not have to pre-approve a hospital-to-hospital transfer
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.
You asked the Plan to pre-approve a tier exception for Novolog. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Novolog have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Novolog.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2744, V2782, V2203, V2203, V2750,
V2020) purchased on March 3, 2021.
You asked the Plan to pay for the eyeglasses. You say that these glasses should be paid for with your $200
benefit allowance. The Plan denied your request. The Plan says the benefit allowance has been applied;
however, you are responsible for the cost that exceeds the $200 limit.
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. The Plan covers up to $200 each year for routine eyewear. You are responsible for costs that exceed
this amount.
We looked at the file and the Plan's rules. The documentation shows that the total cost of the eyeglasses is
$573. The Plan paid $200, and you are being asked to pay $373, which is the remaining cost. This means that
you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided
that the Plan does not have to pay any additional amount for the eyeglasses (V2744, V2782, V2203, V2203,
V2750, V2020) purchased on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services provided on February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the breast (77049) provided March 10, 2021.
You asked the Plan to waive the copayment for the MRI of the breast. You say that this cost share seems excessive. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 Medicare covered diagnostic imaging service. You have been asked to pay a $275 copayment for the MRI of the breast. This service falls within the Medicare covered diagnostic imaging service 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 the magnetic resonance imaging (MRI) of the breast (77049) provided March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve SNF admission. You say that you would like reconsideration because SNF admission is medically necessary and urgent. The Plan denied your request. The Plan says the member's needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's care needs are custodial and, as a practical matter, can be provided 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received January 23, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have a copayment for ambulance services. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $225 copayment for Ambulance Services. You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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
the ambulance transportation (A0427, A0425) received January 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on January 7, 2021.
You asked the Plan to pay for the paramedic intercept services. You say that you were treated in place by the paramedics. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on January 7, 2021.