Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for nerve blocks (01992-P3-AA) provided on June 10, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says minor pain procedures under most routine circumstances do not require anesthesia careother than local anesthesia.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 anesthesia services. Our reviewer says that minor pain procedures under most routine circumstances do not require anesthesia care other than local anesthesia. Our physician reviewer found the clinical records provided did not support the P3 (ASA 3) indicator for this member. There was no documentation as to the enrollee's condition that warranted the P3 modifier or the overall medical necessity for the need of monitored anesthesia 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 the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for nerve blocks (01992-P3-AA) provided on June 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered to enrollee on July 17, 2019.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 procedure codes 23472-AS-22-LT and 23412-AS-59-LT are not supported.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 code 23472 is arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder)). The definition of code 23412 is repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic.We find that CPT codes 23472 and 23412 are not supported in the medical record. Specifically, the records do not contain documentation of increased procedural services of a total shoulder arthroplasty of the glenohumeral joint to support code 23472 or documentation of an open repair of ruptured musculotendinous cuff to support code 23412. 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 for the assistant surgeon services rendered to enrollee on July 17, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the pelvis and knees for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatan arthroplasty has not been requested or approved.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer tocarefully 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 scan. Our reviewer says that the requested scan is medically reasonable or necessary. Our physician reviewer found the operating surgeon considers CT scan of the pelvis and both knees to be necessary for operative planning. There is a complex history of sciatica, right hip pain, and radiographic evidence of right hip arthritis.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the pelvis and knees for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee on November 1, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence garments (pull-ups).
You asked the Plan to pre-approve incontinence garments. You say that you have been taking medicines and heating pads but still have accidents when you walk, get up or cough so you need the pull-ups. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garments (pull-ups).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CYP gene panel testing provided to the enrollee from November 7, 2019 to November 15, 2019.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says CYP gene panels is a single unit of service, and the LCD gives coding instruction for what code to use to report all CYP panels.
The Plan must follow Medicare rules. Medicare rules say that CYP gene panels should be coded as a single unit of service. Additionally, they are not covered. The denial is two-fold. The services should have billed with just simply CPT 81479. Additionally, CYP gene panels are not covered. 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 CYP gene panel testing provided to the enrollee from November 7, 2019 to November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on August 7, 2019.
You asked the Plan to pay for the nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 nursing facility care provided on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services provided to the enrollee on October 2, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 fordrug testing services provided to the enrollee on October 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you fell between your bed and the bedroom wall and you could not get up. Your wife was unable to help you up and so she called 911 for assistance. The responders arrived and after helping you up, they treated you and evaluated your vitals. You were offered transport to the hospital but you refused. You say that the call for help was necessary and should be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 10, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee on June 5, 2019 and billed under codes 80307 and G0483.You asked the Plan to pay forthis testing. You say that this claim should be paid.The Plan denied your request. The Plan says the records provided do not contain a valid physicians orderor specific documentation as to why this testing was medically necessary.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on June 5, 2019 and billed under codes 80307 and G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you were notified there was a need for a bath chair and you found out later that it is not covered. You say the requested equipment is urgently needed because the enrollee has Alzheimer's and diabetes, and had open heart surgery. The Plan denied your request. The Plan says this item 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 shower chair.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the chest for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatadvanced imaging is not supported to look at or follow-up on the lung nodule.The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found first, it is true that the stability of the nodules over a period of 2 years would indicate they are benign. However, the report of the 6/19/19 CT recommends a 6 month followup not for the nodules but for the airspace changes in the lung bases. Such a followup is reasonable especially in a patient with significant smoking history. Also, it is important to document that this enrollee will qualify per CMS guidelines for annual low dose CT for lung cancer screening.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the chest for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 23, 2019 to October 5, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 23, 2019 to October 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued treatment with Opdivo.
You asked the Plan to pre-approve continued treatment with Opdivo. You say that the requested continuation of Opdivo is medically necessary. The Plan denied your request. The Plan says the requested continuation of Opdivo is not medically necessary.
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 continued treatment with Opdivo. Our reviewer says that the requested continuation of Opdivo is not medically necessary. Our physician reviewer found the enrollee is diagnosed with progressive liver cell carcinoma. Opdivo (nivolumab) is FDA approved for the treatment of hepatocellular carcinoma (HCC) in patients who have been previously treated with sorafenib. This enrollee has already received nivolumab with progression while on the medication as well as another immunotherapy. There is no compendia support for off label use and treatment with another immunotherapy after progression on an immunotherapy is not a standard of care or supported by the medical literature. The service is not reasonable or 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 continued treatment with Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve continued treatment with Opdivo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from November 4, 2019 through November 6, 2019.You asked the Plan to pay foracute 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 doctorexpects 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 the admitting history and physical exam notes the enrollee was being admitted to observation telemetry with an anticipated discharge of less than 2 midnights. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. She had stable vital signs and was improved at the time of the 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 forthe acute inpatient hospital care provided from November 4, 2019 through November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin surgery provided on September 12, 2019.You asked the Plan to waive the copayment for the skin surgery. You say that you had a skin tag removed and not surgery. You say it was performed in the same office as your office visits. 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 $350 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the skinsurgery.You have been asked to pay a $337.52 copayment for the skin surgery. The skin surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the skin tag removal is considered a surgical procedure. The record also shows you were billed by an outpatient hospital facility.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 skin surgery provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient office visit and ophthalmological services to be provided by an OONprovider.You asked the Plan to pre-approvethe outpatient office visit and ophthalmological services. You say that youare asking to see another retina specialist. You also say that you will use any provider other than the previous provider you have seen.The Plan denied your request. The Plan says the provider you requested to see is OON with your plan.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe outpatient office visit and ophthalmological services to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from October 31, 2019, to November 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 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 medical services provided to the enrollee by an out-of-network provider from October 31, 2019, to November 7, 2019.