Persius/hicric huggingface dataset:
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 enrollee cannot be restored at any other level of care. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be treated in the current hospital.
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 in this case the enrollee was admitted with septic shock secondary to obstructive uropathy. She remains tachypneic with concerns of recurrent aspiration pneumonia. She is awaiting a PEG tube. She continues to receive acute care services, and these have not been denied. The medical record does not indicate that she requires services that she is not currently receiving but that would be available at the LTACH facility. Therefore, the requested services 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for semi-electric hospital bed (E0260) elevating leg rests (K0195) wheelchair anti-tipping device (E0971) hydraulic patient lift (E0630) general wheelchair cushion (E2601) and high strength, lightweight wheelchair (K0004) provided January 18, 2021.
You asked the Plan to waive the coinsurance for the DME items. You say that you should not have to pay for service after already paying the estimate. You feel this amount should be waived. The Plan denied your request. The Plan says the claim was processed, and the correct cost share was applied per the Evidence of Coverage.
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% coinsurance for covered items and related supplies.
You have been asked to pay $74.49 for the DME items. The allowed amount for the hospital bed, semi-electric is $99 with coinsurance of $19.80. The allowed amount for the elevating leg rests is $16.04 with coinsurance of $3.21. The allowed amount for the anti-tipping device for wheelchair is $2.81 with coinsurance of $0.56. The allowed amount for the patient lift, hydraulic is $82.50 with coinsurance of 16.50. The allowed amount for the wheelchair seat cushion is $58.10 with coinsurance of $11.62. The allowed amount for the high strength, lightweight wheelchair is $14 with coinsurance of $22.80. The DME items falls within the Durable medical equipment (DME) and related 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 waive the coinsurance for semi-electric hospital bed (E0260) elevating leg rests (K0195) wheelchair anti-tipping device (E0971) hydraulic patient lift (E0630) general wheelchair cushion (E2601) and high strength, lightweight wheelchair (K0004) provided January 18, 2021.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 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 There is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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: 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 December 3, 2020.
You asked the Plan to pay for the test. You say that this should be covered based on medical necessity. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the test. Our physician reviewer found the review indicates that the GeneSight Psychotropic is a genetic panel that provides clinicians additional information about specific genetic variants to assist with decisions about drug selection regarding "psychotropic medications commonly prescribed to treat depression, anxiety, bipolar disorder, posttraumatic stress disorder (PTSD), obsessive compulsive disorder, schizophrenia and other behavioral health conditions." GeneSight tests for genetic variants in multiple pharmacokinetic and pharmacodynamic genes, which may impact drug tolerance and/or drug response. Specifically, the test currently analyzes 12 genes that may affect an individual's response to ~56 antidepressant and antipsychotic (psychotropic) medications (including 4 pharmacodynamic genes and 8 pharmacokinetic genes). In 2010, the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Major Depressive Disorder stated, "In time, genetic testing may help guide selection or dosing of antidepressants, but data are currently insufficient to justify the cost of such tests."13In addition, in 2018, The APA Task Force for Biomarkers and Novel Treatments stated, "at present there are insufficient data to support the widespread use of combinatorial pharmacogenetics testing in clinical practice. The review has determined that the services were not supported by the medical records. 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 pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provided
on February 1, 2021, and February 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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 to you by an out-of-network provided on
February 1, 2021, and February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on January 4, 2021.
You asked the Plan to pay for the GeneSight Psychotropic test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that GeneSight Psychotropic test is 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 pay for the GeneSight Psychotropic test. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has failed treatment with Cymbalta the enrollee's physician is trying to change the medication. The documentation does not support that the enrollee met LCD criteria for the testing provided. 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 GeneSight Psychotropic test have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0428, A0425, A0382) provided on November 28, 2020.
You asked the Plan to pay for the ambulance services. You say that these services were billed correctly and should be covered. The Plan denied your request. The Plan says that the basic ambulance supplies (A0382) cannot be paid because Medicare guidelines say that these supplies are included in the ambulance service and are not paid separately. It was also determined that the ambulance transportation (A0428) and mileage (A0425) were processed correctly. These services were denied because they did not include the appropriate primary, first listed or principal diagnosis. The ICD-10 code provided is a secondary only diagnosis and cannot be used as the primary diagnosis for any procedure or service. No valid primary diagnosis was listed on this claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules also say that ambulance supplies are no longer paid separately for ambulance services.
We find that CPT code A0382 is not supported in the record. Specifically, ambulance supplies are not separately payable. Per the Ambulance Fee Schedule, payment for these supplies is included in the base payment for the ambulance services.
We also find that CPT codes A0425 and A0428 are not supported in the record. This claim was billed with an inappropriate first-listed diagnosis code. Per Medicare, diagnosis code J69.8 includes a code first note which indicates that the etiology or underlying condition code should be listed first.
Based on this information, we decided that Medicare rules for coverage of the ambulance services and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0428, A0425, A0382) provided on November 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) skull base to mid-thigh (78815).
You asked the Plan to pre-approve a PET-CT scan. You say that the enrollee has recurrent prostate cancer status post radiation therapy with post treatment PSA initially up to 307. The Plan denied your request. The Plan says the request for PET-CT does not meet medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET-CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has recurrent prostate cancer and is being treated with androgen deprivation therapy. He had a transient rise in January 2021 to 1.37. The PSA has decreased to 0.77 with treatment. This is his baseline PSA. The medical record does not indicate that the requested test is being used to change or guide therapy. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET-CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) skull base to mid-thigh (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the L300 Go Thigh Plus system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary, as there is peer-reviewed clinical support for this device. The Plan denied your request. The Plan says this item does not meet the requirements for approval.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the L300 Go system that was approved already includes a thigh stimulator and the request for the L300 Go Thighplus exceeds the enrollee's medical need. The requested L300 Go Thighplus does not meet the Medicare medical necessity criteria as it is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the L300 Go Thigh Plus system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), a power seat elevation system (E2300), and an attendant control (E2331).
You asked the Plan to pre-approve an expandable controller, a power seat elevation system, and an attendant control. You say that the enrollee needs these items. The Plan denied your request. The Plan says these items are not necessary.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically necessary for the functions described in the LCD. A power seat elevation feature is non-covered because it is not primarily medical in nature. An attendant control is non-covered if it is provided in addition to a beneficiary-operated drive control system. 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 an expandable controller, a power seat elevation system, and an attendant control. Our reviewer says that the requirements for coverage of these items have not been met. Our physician reviewer found based on the medical records provided there is no documentation that the requested expandable controller is medically necessary. Records indicate the enrollee has 4-/5 right hand strength and 4/5 left hand strength and is independent with grooming indicating sufficient upper extremity strength and function to operate the power options with their own switches. The power seat elevation is not a covered item. The attendant control is not covered in addition to a beneficiary-operated drive control system, which has been approved 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 an expandable controller, a power seat elevation system, and an attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), a power seat elevation system (E2300), and an attendant control (E2331).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that there is no documented rational for this stay.
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 care. Our physician reviewer found that from a nursing perspective, the enrollee needs a course of intravenous antibiotics through July 17, 2021. There are identifiable skilled nursing service needs. Regarding rehab services, he is at a maximal assist level with functional mobility. He requires varying assist with activities of daily living. He tolerates a mechanical soft diet and thin liquids. There are identifiable skilled therapy service needs. The enrollee does require skilled services on a daily basis. He does meet severity of illness and/or intensity of service criteria for 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
December 8, 2020, to December 17, 2020.
You asked the Plan to pay for the SNF services. You say that you feel there was a medical need for
continuation of care for the enrollee. You also say that the enrollee was discharged from the skilled nursing
facility too soon. The Plan denied your request. The Plan says the private pay stay is not covered.
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 pay for the SNF 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 SNF services have not been met. Specifically, the enrollee did not receive
skilled services on the dates of services in this case. Therefore, we decided that the Plan does not have to pay
for the skilled nursing facility (SNF) services provided from December 8, 2020, to December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says LTACHs do not provide a clinical advantage over a non-LTACH acute care hospital.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 admission to a long term acute care hospital (LTACH).