Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 23, 2021, to March 3, 2021.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that care could have been provided as outpatient.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 23, 2021, to March 3, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OmniSeq Insight panel test.
You asked the Plan to pre-approve the test. You say that this test will be able to identify any blood vessels going to the tumor. The Plan denied your request. The Plan says there is no clinical utility to this testing.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the test. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found OmniSeq Insight is a genomic test that interrogates the coding region of 523 genes. The available documentation does not support that OmniSeq will impact your management and outcomes 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 the test have not been met. Therefore, we decided that the Plan does not have to
pre-approve the OmniSeq Insight panel test.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the MRI provided on March 6, 2021.
You asked the Plan to pay for the MRI. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the claim submitted is an exact duplicate to a previously submitted claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment stating that the submitted claim is an exact duplicate to another claim that had previously been submitted. However, the Plan did not provide the initial claim to verify if both claims are exact duplicates. Therefore, we decided that the Plan has to pay for the MRI provided on March 6, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from August 28, 2019 to August 30, 2019.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.

The Plan denied your request. The Plan says you received inpatient hospital care on the dates of service at issue
in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $250
copayment per day for days 1-6 for Inpatient hospital care.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient
hospital services from August 28, 2019 to August 30, 2019. You have been asked to pay a $250 copayment per
day for days 1-2 for the inpatient hospital services, totaling $500. The inpatient hospital services fall within the
Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient
hospital services provided from August 28, 2019 to August 30, 2019.

Your complaint about being discharged too soon is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network
(OON) provider on October 2, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the drug testing (G0480) rendered by
the out-of-network (OON) provider on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the programming device evaluation (93280) provided on February 8, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 per visit to a specialist.

You have been asked to pay a $35 copayment for the specialist visit provided. 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 programming device evaluation (93280) provided on February 8, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on September 10, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services provided on September 10, 2020. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus-xT Panel provided on October 22, 2020.

You asked the Plan to pay for the Tempus-xT Panel. You say that you would like reconsideration because this
testing was medically reasonable and necessary. The Plan denied your request. The Plan says if one laboratory
procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report
only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte
assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

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 Tempus-xT Panel. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Tempus xT gene panel is a targeted panel of 648 genes. It has not been
demonstrated that the gene panel would impact the management and outcome of the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Tempus-xT Panel have not been met. Therefore, we decided that the Plan
does not have to pay for the Tempus-xT Panel provided on October 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by a marriage and family therapist.
You asked the Plan to pre-approve outpatient mental health services to be provided by a marriage and family therapist. You say that there are not other counselors in your area that specialize in trauma and addiction. The Plan denied your request. The Plan says the requested provided in not and cannot be enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Marriage Family Therapists are not eligible to enroll in Medicare. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services to
be provided by a marriage and family therapist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95810).

You asked the Plan to pre-approve the sleep study. You say that the test is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Polysomnography, or sleep studies, are not covered in cases where seizure disorders have not been ruled out. 

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 sleep study. Our reviewer says that the requested sleep study is not medically necessary. Our physician reviewer found seizure activity has not yet been ruled out for this patient, and there were no records to show a sleep disorder such as sleep apnea. 

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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study (95810).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 30, 2020 by an
out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.

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 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 laboratory services provided on November 30,
2020 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report
rendered on November 15, 2020.

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 code 93010 is 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 93010 is electrocardiogram, routine ECG with at least 12
leads; interpretation and report only.

We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of
an interpretation and report of an EKG with at least 12 leads.

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 electrocardiogram (EKG) interpretation and
report rendered on November 15, 2020.
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.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 the enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular and gene variant testing (81408, 81407, 81439 and 81286) provided on July 15, 2020.
You asked the Plan to pay for the cardiovascular and gene variant testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease.
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 cardiovascular and gene variant testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no medical history of cardiovascular disease or cardiomyopathy. There is no family history of cardiomyopathy or arrhythmias. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. 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 cardiovascular and gene variant testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular and gene variant testing (81408, 81407, 81439 and 81286) provided on July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that it is felt that this would be an appropriate treatment for the enrollee's condition. The Plan denied your request. The Plan says there is not sufficient support for this procedure.
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 Superion procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 73-year-old male was being treated for spinal stenosis, lumbar region, with neurogenic claudication. He presented with continued pain in the back with standing and walking. He reports he is pain-free sitting. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate"
spinal stenosis (including the planned levels of implantation at L3-4 and L4-5.) Furthermore, there is no
updated imaging provided after the bilateral decompression laminotomy L3-4 and L4-5 on 3/23/21. FDA
contraindications include spinal instability, scoliosis, obesity, and osteoporosis. These have not been
adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension
films. There is no documentation of the enrollee's height, weight or body mass index. There is no discussion of
scoliosis of the lumbar spine, along with the lack of documentation of applicable Cobb angle. There is also no
discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient.
Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical
necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion
interspinous device at L3-4 and L4-5 is not medically reasonable or 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 Superion procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve placement of the Superion interspinous spacer.