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

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on June 6, 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 according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service HCPCS G0482: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the records do not support an established relationship between the enrollee and the ordering physician. There were no claims submitted for an evaluation and management service. A review of claims history for this enrollee, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on
November 4, 2019 to December 18, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you saw the
physician's assistant and should not be charged the specialist's copayment because you did not see the doctor.
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 Medicare-covered specialist visit.
You have been asked to pay a $35 copayment for each of the specialist office visits. The specialist office visits
fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record
shows that a Physician's Assistant is considered a Practitioner at a specialist's office.
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 copayments for the specialist office visits provided on November 4, 2019
to December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on October 30, 
2019. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you disagree with the charges 
because you met the MOOP amount for the year. 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 the MOOP amount for 
2019 is $6,700. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare 
Part B prescription drugs. 
 
You received chemotherapy on October 30, 2019. The record shows that due to the reprocessing of claims you 
had only paid $5,273.37 toward the MOOP amount of $6,700. Therefore, you are responsible to pay the 
amount of $1,466.63, which is less than the total coinsurance amount.   
 
You have been asked to pay the total coinsurance amount of $1,466.63 for chemotherapy. Chemotherapy falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for chemotherapy provided on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased February 27, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that you are appealing the denial of the portable oxygen concentrator that you needed to leave home. The Plan denied your request. The Plan says this item is not a covered benefit. Medicare only covers rental of oxygen equipment, not purchases.
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. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services rendered from December 4, 2019 to December 31, 2019.
You asked the Plan to pay for these services. You say that you do not understand why the claims are being denied. The Plan denied your request. The Plan says the services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services rendered from December 4, 2019 to December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 8, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says the test should be reported with CPT 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and injection services provided on January 7, 2020.
You asked the Plan to pay for the office visit and injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were 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 pay for the office visit and injection services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with seasonal allergic rhinitis. The enrollee was seen in the office and injected with dexamethasone and triamcinolone. The first line treatments for allergic rhinitis, which are standard of care, include oral antihistamines and/or intranasal steroids due to lower risks and significant clinical benefit over systemic or injectable corticosteroids. The provided documentation did not clearly justify using injected corticosteroids for this condition and did not show failure or contraindication to the above first-line treatment options. Therefore, the enrollee did not meet criteria for the services rendered. 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 office visit and injection services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit and injection services provided on January 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 8, 2020 to March 3, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 8, 2020 to March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head (70450) 
provided January 25, 2020. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary and only one 
service was performed. The Plan denied your request. The Plan says payment was already issued for CPT code 
70450 on this service date. 
 
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 70450 is not supported in the medical record. Specifically, the record shows payment 
was already issued for CPT code 70450 on this date of service. The claim did not include modifier 77 to 
indicate a repeat service. Based on this information, we decided that Medicare rules for coverage of the CT 
scan have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography 
(CT) scan of the head (70450) provided January 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided June 10, 2019.
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.
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 71045 is not supported in the medical record. Specifically, a claim was already processed for this service on the same date of service. The claim did not include the correct modifiers to denote a repeat service and the records do not indicate a repeat service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an out of network (OON) provider.
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 rendered by an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an out of network (OON) provider.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 was admitted to the acute care hospital with sepsis. His medical history is notable for heart disease, diabetes, hypertension, dementia, and recurrent episodes of sepsis. The enrollee required intubation, and was subsequently extubated. The enrollee developed acute kidney injury on chronic kidney disease and now requires dialysis. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. 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. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive this care in another setting.
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. You appear to require additional acute care services, however, you are likely to be stable with current treatments in less than 25 days and be able to continue therapy at a lower level of care when ready. You do not require services at the LTACH that are not already available at the current acute care facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CIMZIA prefilled syringe kit for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee needs this drug. 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 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 CIMZIA prefilled syringe 
kit for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that inpatient rehab level of intensive therapy exceeds member's need.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The patient does not require treatment by multiple therapies, including physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although the patient requires physical and occupational therapy, the record does not plausibly support a need for intensive therapy and services could safely and effectively be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.
You asked the Plan to pre-approve facet injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve facet injections. Our reviewer says that the documentation does not support that the requested facet injections are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of chronic low back pain, facet arthritis, degenerative lumbar spine, and radicular pain of right lower extremity. Prior steroid injection bilateral L2-L3 and L3-L4 facets on March 10, 2020 provided immediate relief with pain rated 0 out of 10. The documentation shows right lower extremity radiculopathy. Although radiculopathy is not specifically mentioned in follow up notes, the enrollee's problem list/past medical history lists this as an ongoing problem. Therefore, the enrollee does not meet criteria for the requested injection 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 facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a swiveling and sliding bathtub transfer bench and shower chair.
You asked the Plan to pre-approve a swiveling and sliding bathtub transfer bench and shower chair. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a swiveling and sliding bathtub transfer bench and shower chair.