Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forosteogenic ultrasound stimltor (E0760) provided on August 15, 2019.You asked the Plan to pay forosteogenic ultrasound stimltor. You say that due to the enrollee's special medical conditions you request reconsideration. Medical necessity is well documented in the records.The Plan denied your request. The Plan says this request is not considered reasonable and necessary and therefore non-covered.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 osteogenic ultrasound stimltor. Our reviewer says that this request for an ultrasonic bone growth stimulator is not medically necessary. Our physician reviewer found There is no clearly documented radiographic evidence of a nonunion fracture (with no clinically significant evidence of fracture healing between the two sets of radiographs 90 days apart.) In the absence of documentation of the radiographic findings as of 7/15/19, there is insufficient evidence to support the medical necessity of an ultrasonic bone growth stimulator consistent with Medicare coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of osteogenic ultrasound stimltor have not been met.Therefore, we decided that the Plan does not have to pay forosteogenic ultrasound stimltor (E0760) provided on August 15, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not had an inadequate response to Retacrit therapy for at least two consecutive months with appropriate dose adjustment.
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 Aranesp. Our physician reviewer found that the enrollee has anemia in chronic kidney disease. The plan requires a trial of Retacrit before they will approve the requested drug. The documentation does not show the enrollee has tried and failed the required drug. The documentation does not support that Retacrit (Epoetin alfa) would likely be less effective, and/or would likely have adverse effects 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla 30mg Tablets.You asked the Plan to pre-approve Otezla. You say that the medication is medically necessary.The Plan denied your request. The Plan says coverage for Otezla is not available under the Part B medical benefit.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 Otezla 30mg Tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the genetic testing provided on October 10, 2019.You asked the Plan to reduce the coinsurance for the genetic testing. You say that the amount you have to pay is too much. You say you would like the amount reduced. 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 20% of the Medicare-allowed amount for each in-network Medicare-covered genetic test in all settings. You have been asked to pay $774.60 which is 20% of the allowed amount for the genetic testing. The allowed amount is $3,873. ($3,873 x 20% = $774.60). The genetic testing falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 reduce the coinsurance for the genetic testing provided on October 10, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granisetron Hcl for the enrollee.
You asked the Plan to pre-approve this drug. You say that the patient would greatly benefit from this drug. The Plan denied your request. The Plan says that this drug is not covered for the enrollee's indication.
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 Granisetron Hcl 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of SNF care.
You asked the Plan to pre-approve the SNF care. You say that you need more time in the facility to meet with physicians and plan accordingly. The Plan denied your request. The Plan says you do not require daily skilled care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in an SNF 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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on October 28, 2019.You asked the Plan to waive the copayment for the cystoscopy. You say that you previously had this procedure and only had to pay $25. You say that you were not advised your liability should be more.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 $100 copayment for outpatient surgery at an outpatient hospital facility.You have been asked to pay a $100 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cystoscopy provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint injections for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and has had epidural steroid injections as well as SI joint injections in the past that provided sustained pain relief. There is no documentation of physical exam findings that support the diagnosis of sacro-ilitis. There is no imaging of the SI joint that supports the diagnosis of sacro-ilitis. There is insufficent documentation to support performing SI joint injections. The procedure is not medically reasonable or necessary at this point. 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 bilateral sacroiliac (SI) joint injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on December 27, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified. 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 laboratory services rendered on December 27, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for complex chronic care management services (99487) provided on October 31, 2019 by an out of network (OON) provider.You asked the Plan to pay for complex chronic care management services. You say that you are requesting reconsideration of the claim for payment.The Plan denied your request. The Plan says a Medicare health plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the health plan must arrange for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. There was no authorization for the service. There are no calls to the Plan from the enrollee or the non-contracted provider prior to services being rendered to verify provider participation or benefit information. In addition,the services were not urgent or emergent in nature.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 forcomplex chronic care management services (99487) provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve moderate sedation during spinal injection.You asked the Plan to pre-approvethe sedation. The Plan denied your request. The Plan says that this 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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the sedation. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the ASA statement on sedation during interventional pain procedures specifically states that sedation is reasonable during RFA due to the long duration of the case. Therefore, the request for sedation is medically reasonable and 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 the sedation have been met.Therefore, we decided that the Plan has to pre-approvemoderate sedation during spinal injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).You asked the Plan to pre-approveProcrit. You say that it is medically necessary for the enrollee to continue with this drug.The Plan denied your request. The Plan says this is an off label use that is not covered.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 Procrit. Our reviewer says that Procrit is not medically necessary for the enrollee at this time. Our physician reviewer found the enrollee has a diagnosis of iron deficiency anemia, unspecified anemia, and macrocytosis. The documentation does not support that the Procrit is safe, effective, and medically necessary for the patient's current condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approveProcrit (J0885)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 16, 2019.You asked the Plan to pay for the 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 stating exactly what tests are to be performed.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 for the drug testing services provided to the enrollee on July 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care provided from July 12,
2019 through July 17, 2019.
You asked the Plan to waive the copayment for observation care. You say that you are appealing your costshare
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2019 EOC benefits. The Plan states they determined that your claim processed
incorrectly. The Plan states they sent your claim for reprocessing to remove the $59.74, $15.77, $24.95, $68.37,
$56.17, $221.09, $3.91, $36.32, $188.68, $107.88, and $20.32 copayments from your responsibility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received observation care provided from July 12, 2019 through July 17, 2019.
You are asked to pay a $225 copayment for the observation services. 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 observation care provided from July 12, 2019 through July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Lynch Sydrome panel test for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this test is helpful for evaluation of the health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the test. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was seen for a full body skin examination. Diagnoses included seborrheic dermatitis, junctional nevus, cherry angioma, seborrheic keratoses, actinic keratoses and a single neoplasm of uncertain behavior. No concern for Lynch syndrome was described in the documentation. The skin diagnoses described do not raise a substantial concern for Lynch syndrome. The services at issue in this case are not medically reasonable and 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 the test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Lynch Sydrome panel test for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 11, 2019 through October 14, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. He had stable vital signs and no complaints at the time of admission. Inpatient services were not supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 11, 2019 through October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebilateral endovenous ablation and bilateral sclerotherapy for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation of attempts at weight loss, daily exercise and period leg elevation for at least six weeks.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are appeal letters provided that are not accompanied by source documents including an updated history and physical examination/assessment and does not include formal duplex reports. The enrollee is already status-post bilateral great saphenous vein ablation, bilateral small saphenous vein ablation and treatment of multiple incompetent perforators of the calf. There is documentation that her deterioration since those treatments was associated with non-use of compression therapy. There is also documentation that even a brief period of conservative treatment resulted in significant improvement. Documentation of a recent assessment of arterial perfusion is not provided. Numerous procedures are being requested to be performed on separate days however there does not appear to be a plan for reassessment between those periods to assess for improvement. In summary, coverage criteria are not met and the documentation does not support an override of the determination on the basis of medical necessity.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 Plandoes not haveto pre-approvebilateral endovenous ablation and bilateral sclerotherapy for the enrollee.