Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for six hours a day.
You asked the Plan to pre-approve home health aide services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 aide services. Our
reviewer says that the documentation does not support that the requested services are medically reasonable or
necessary. Our physician reviewer found you are limited by arthritis and pain and needs assistance with
dressing, bathing and toileting. You get around with a walker or wheelchair. The documentation supports that
you require home health aide services, however, the documentation does not support that six hours per day is
necessary for the treatment of your illness or injury by the skilled professional staff. Therefore, you do not meet
criteria for the requested six hours per day of home health aide services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the
Plan does not have to pre-approve home health aide services for six hours a day.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Opdivo. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of the lung (small cell lung cancer) and has experienced disease progression while on chemotherapy and Tecentriq, a PD inhibition immunotherapy medication. The current evidence suggests very little to no survival outcome differences between the PD inhibitors including Tecentriq and Opdivo to support trying more than one PD inhibitor. Therefore, as this enrollee had tried and failed Tecentriq, it is not medically reasonable or necessary for the enrollee to try Opdivo therapy as the outcome is likely to be the same, based on current evidence. Although the safety of the medication would be very similar to the Tecentriq already tried, the effectiveness would likely be poor as the enrollee had failed Tecentriq, another PD inhibitor. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.
You asked the Plan to pre-approve inpatient hospital services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan 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 inpatient hospital services. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found you were most recently evaluated in the emergency department. You were
treated with IV meropenem, and urine culture showed no predominant pathogens but discharged with
order/plan for continuation of IV mertapenem via midline catheter via home health. You are scheduled for a
follow up telephone appointment with your primary care physician, at which time there were no urinary
complaints or concerns, your urine upon change of catheter was clear and yellow. The documentation does not
support that you have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of
inpatient services. The requested inpatient services are not considered the standard of care for the treatment of
your condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 19, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1843).
You asked the Plan to pre-approve the knee brace. You say that you would like reconsideration because the knee brace is medically necessary. The Plan denied your request. The Plan says the billed supply is not supported by the submitted medical records.
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 knee brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal a recent injury to or a surgical procedure on the knee. You are ambulatory, but there is no objective evidence of instability.
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 knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace (L1843).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on September 16, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you needed a prescription filled and left the ER shortly after being triaged and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay the allowed amount of $72.14, which is less than the $90 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 01480) provided to the enrollee on November 25, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied because it was billed with modifier QZ.
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 01480 is "Anesthesia for open procedures on bones of lower leg, ankle, and foot." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted was reviewed. Operative report does not clarify that the CRNA performed anesthesia without the direction of a qualified practitoner. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (CPT 01480) provided to the enrollee on November 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a SNF.
You asked the Plan to pre-approve the SNF admission. You say that a safer transition to home would benefit from skilled nursing for a brief time period. You also say that the enrollee lives alone and lacks community support. The Plan denied your request. The Plan says the service does not meet criteria and is not medically necessary. The Plan also says that the enrollee can get the care they need at a lower level, such as home with home health.
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 admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a SNF.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397)
provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the orthosis and sleeve. 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 for knee orthosis (L1851) and
suspension sleeve (L2397) provided to the enrollee on December 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for medication provided during an out of country emergency
room visit from February 7 - February 14, 2020.
You asked the Plan to pay for the medication provided out of country. The Plan denied your request. The Plan
says prescription drugs provided outside of the United States is not covered.
The Plan must follow Medicare rules. Medicare rules say that services furnished outside the United States are
generally excluded from coverage. The Plan contract specifically advises that prescription drugs provided
outside of the United States are not covered under the contract.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of out of country services have not been met. Therefore, we decided that the Plan does not have to
pay for medication provided during an out of country emergency room visit from February 7 - February 14,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatry services rendered to you from January 7, 2019
to November 1, 2019.
You asked the Plan to pay for these services. You say that you didn't fully understand the requirements for
reimbursement. The Plan denied your request. The Plan says the provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are
furnished by a provider or supplier enrolled in the Medicare program.
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal.
Therefore, we decided that the Plan does not have to pay for the psychiatry services rendered to you from
January 7, 2019 to November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CXbladder test provided to the enrollee on October 16,
2019.
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The
Plan says the cancer guidelines say that it is not clear this test offers additional information that is helpful for
detecting or managing bladder cancer.
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 test. Our reviewer says that the services
at issue in this case were not medically reasonable or necessary. Our physician reviewer found the
documentation supports the enrollee was treated with BCG for bladder cancer in 1997. The enrollee had
subsequent recurrence in 1998 and 1999. Documentation supports the requested test is being used as a
screening test to evaluation for disease recurrence. Review of the compendia note the use of this test is not
conclusive for providing additional data in management and diagnosis of bladder cancer. With the support of
the compendia, medical necessity cannot be determined.
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 the CXbladder test provided to the enrollee on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on February 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on February 12, 2020.
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 received a bill for the ambulance services and it was upsetting. You say that on the date of service the enrollee had fallen and 911 was called to help him back up. You stated that you would not have been able to help him up under any circumstances. The responders helped the enrollee up and assisted him back into his bed. You stated that the enrollee felt it was not necessary to go to the emergency room and you were unaware that the services were only covered for transportation. You say that you do not believe that it makes sense and you do not believe it is a fair way to handle the situation. 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 December 7, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on January 22, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis (L3960). You say that the Plan should pay this claim. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The medical record does not mention, or support medical necessity for, the orthosis. Based on this information, we decided that Medicare rules for coverage of the shoulder elbow wrist hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 6, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not support the testing as billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS). Medicare rules say that a valid physician
order or clear intent to order specific lab services is required for covered lab services.
We looked at the file and Medicare rules. The Plan's denial on the basis that this claim was billed with Place of
Service (POS) code 81 is not supported, because the claim form submitted includes a Place of Service (POS)
code of 11. However, the documentation submitted does not include a valid physician order or clear intent to
order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules
for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug
testing provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 PMD.
You asked the Plan to pre-approve the group 3 PMD. You say that you would like reconsideration because you find it difficult to walk and this PMD will allow you to be mobile. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a PMD.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 3 PMD. Our reviewer says that the documentation does not indicate that your mobility deficit impairs your participation in MRADLs. Our physician reviewer found the documentation does not indicate that you are unable to use an assistive device. 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 group 3 PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 PMD.