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

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on June 7, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that the polyp removal is a part of the screening process and not subject to the copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $240 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. The enrollee has been asked to pay a $240 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the colonoscopy was performed due to chronicdiarrhea, clinically significant diarrhea or unexplained origin, and irritable bowel syndrome which makes the colonoscopy diagnostic in nature. The record also shows that polyps were removed which makes the colonoscopy a surgical procedure. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive thecopayment forthe colonoscopy provided on June 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided, skilled nursing services are not required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Your conditions are chronic and the memory issues with regard to medication administration are not likely to improve due to your underlying dementia. Lower level services in the home with a caregiver appear to be more appropriate for you 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Low Dose Computed Tomography (LDCT) Lung Cancer Screening provided December 30, 2019.You asked the Plan to pay forthe LDCT Lung Cancer Screening. You say that the service was medically necessary.The Plan denied your request. The Plan says no medical records were received to support the service at issue.The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due. We looked at the file and Medicare rules. The plan made three requests for additional medical records to support the service provided. No records were received. Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening have not been met.Therefore, we decided that the Plan does not have to pay fora Low Dose Computed Tomography (LDCT) Lung Cancer Screening provided December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the LTACH that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the your diagnosis and condition 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: 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 the SNF services. You say that the enrollee is not able to make decisions for herself due to dementia. You say that the enrollee is not able to understand her medical condition, safety, and risks. You say that the enrollee should go to a SNF to receive rehab and to obtain care until she is deemed appropriate to go live alone.The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care that must be provided in a SNF. The Plan says that the enrollee does not require daily skilled rehabilitation therapy.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly contact-guard assist to stand-by assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea behavioral health residential program.You asked the Planto pre-approvethe program. You say that you need a 28 day inpatient program, and not a year-long program.The Plandenied your request. The Plansaysthis is not a covered benefit, and the appropriate alternative level of care would be substance abuse intensive outpatient program.The Plan must follow Medicare rules. Medicare rules say that itemsand 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 program. Our reviewer says that the requested program is not considered medically reasonable and necessary in this case. Our physician reviewer found you were not showing any medical instability was noted to have COWS score of 1. There was no documented depressive symptomatology requiring this level of care. You had stable vital signs with a pulse of 74, BP 152/90 and respirations 18 and Temp 97.7. There is no documentation of inability to perform ADLs. Based on the information provided in the record, you did not meet the criteria for residential treatment for substance abuse or behavioral health as you are not a danger to yourself or others, did not have auditory or visual hallucinations and was able to care for yourself and not showing any signs or symptoms of withdrawal but could be treated in a lesser restrictive environment.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 program have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea behavioral health residential program.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forprovider visit. You say that there were no other providers available to treat the enrollee, and the nursing facility ordered this service.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 forthe medical services provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ConfirmMDx testing provided on July 30, 2019.You asked the Plan to pay forthe provided testing. The Plan denied your request. The Plan says the testing would be appropriate in the future when contemplating a repeat biopsy, but not at this time.The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is only covered under certain medical 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 pay for the provided testing. Our physician reviewer found that the enrollee hasa diagnosis of unspecified disorder of the prostate. He has an elevated PSA. On exam, there were no prostate nodules. A prostate biopsywas negative for prostate cancer in 12/12 cores. ConfirmMDx was performed on the tissue sample. The documentation does not support that the enrollee is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.Therefore, the provided testing was 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 provided testing have not been met.Therefore, we decided that the Plan does not have to pay forthe ConfirmMDx testing provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99497 provided on December 18, 2019.You asked the Plan to pay for CPT code 99497. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. In this case, CPT code 99497 is a column two code and cannot be billed with column one code, 99220.Therefore, we decided that the Plan does not have to pay for CPT code 99497 provided on December 18, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Denosumab.
You asked the Plan to pre-approve Denosumab. The Plan denied your request. The Plan says that the enrollee does not have castrate-recurrent disease.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Denosumab. Our physician reviewer found that the request is for Denosumab to treat bone metastases of castration sensitive prostate cancer. The drug is FDA approved in patients with bone metastases from solid tumors. The NCCN compendium specifically lists the use in castration resistant prostate cancer. It does not specify that it is not acceptable to be used in castration sensitive disease. None of the compendia list the drug as not indicated, not supported or not recommended for the requested use. Therefore, the requested drug 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 Denosumab have been met. Therefore, we decided that the Plan has to pre-approve Denosumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compressor device (E0651 and E0667) provided
on September 30, 2019.
You asked the Plan to pay for the pneumatic compressor device.. You say that you would like reconsideration
because the billed supplies are medically necessary. The Plan denied your request. The Plan says the
documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies
on the billed date of service.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the
supplies provided in this case. Additionally, the records provided do not verify the billed supply as there are
inconsistencies regarding the member's address, delivery address and member signature. Therefore, we decided
that the Plan does not have to pay for a pneumatic compressor device (E0651 and E0667) provided on
September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair electronic upgrades.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs a Group 3 power wheelchair, accessories, and electronic upgrades The Plan denied your request. The Plan says the electronic upgrades cannot be covered as it is not medically necessary to control the three approved power options through the joystick.
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 power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). Our reviewer says that the requested electronic upgrades are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee requires a proportional input device (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick, a non-proportional input device (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the joystick. The enrollee does not need an expandable controller to be able to operate one or more of the following: a separate display (i.e., for alternate control devices); other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) or an attendant control. The documentation indicates the enrollee has sufficient functional ability in the upper extremities (can self-feed and use a joystick independently) to control the power features through their own individual switches. Therefore the requested E2311 Electronic connection, E2377 Expandable Controller, and E2313 Expandable Controller Harness are not 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 the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair electronic upgrades.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approve additional transportation. You say that you need transportation to go to the doctor.The Plan denied your request. The Plan says you have exhausted the transportation benefit for the plan year.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan's maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sphygmomanometer/blood pressure apparatus with cuff and stethoscope. You asked the Plan to pre-approve a home blood pressure monitor. The Plan denied your request. The Plan says that this is not covered. The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a Sphygmomanometer/blood pressure apparatus with cuff and stethoscope.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not beaddressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, you are mostly moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted and reasonable period.We looked at this physician's review, the file, and Medicare rules. Basedon 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-approveacute inpatient rehabilitation facility (IRF) admission and services.