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

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on December 4, 2019.You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians custom profile.The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary.We find that the drug testing is not supported in the medical record. There insufficient evidence that shows the testing was individualized to specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement.Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a heavy duty walker.You asked the Plan to provide a heavy duty walker (E0149). You say that the enrollee needs an extra wide/heavy duty walker.The Plan denied your request. The Plan says the enrollee does not weigh 300 pounds or more.The Plan must follow Medicare rules. The rules say that a walker is necessary for an enrollee who has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.The enrollee does not meet the weight criteria for the requested walker. Therefore, we decided that the Plan does not have to provide a heavy duty walker.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea low dose CT scan for lung cancer screening for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical information provided does not describe an indication for CT imaging.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 not medically reasonable or necessary. Our physician reviewer found the enrollee is 79 years old, and outside of the age range for this scan. The enrollee quit smoking 30 years ago, and the NCD criteria require quitting with in the past 15 years, or still smoking. The enrollee is not asymptomatic, and they have a two month history of shortness of breath.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 not been met.Therefore, we decided that the Plandoes not haveto pre-approvea low dose CT scan for lung cancer screening for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a stress echocardiogram (93350).You asked the Plan to pre-approve the echocardiogram. You say that the service is medically necessary.The Plan denied your request. The Plan says that coverage criteria is not met.The Plan follows Medicare rules. Medicare rules say that stress echocardiography is covered when 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 echocardiogram. Our reviewer says that the requested procedure is medically necessary. Our physician reviewer found the enrollee has increased coronary risk (age and hyperlipidemia), atypical chest pain and a normal electrocardiogram. In this circumstance of intermediate pretest risk and atypical chest pain a stress echocardiogram is considered appropriate under current guidelines.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 echocardiogram have been met.Therefore, we decided that the Plan has to pre-approve a stress echocardiogram (93350).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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says the requested services are available within the plan network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B injection and its administration provided on February 27, 2020.You asked the Plan to waive the cost share for the Part B injection and its administration. You say that you need to have this shot twice a year and it will be expensive and your previous insurance paid for all of it. 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 20% coinsurance for other Part B covered drugs and a $275 copayment Medicare-covered outpatient hospital services. You have been asked to pay a total of $292.10 for the Part B injection and its administration. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. The administration falls within the "Outpatient hospital services" 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 cost share forthe Part B injection and its administration provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you were never told that this provider didn't take your health insurance.The Plan denied your request. The Plan says prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for physician services provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 7, 2020.
You asked the Plan to pay for the physician's services. 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 physician's services provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 22,
2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you contacted the Plan and
asked if they would cover the $195.00 for the evaluation with the periodontist. You also say that the
representative told you to go ahead and get the evaluation. The Plan denied your request. The Plan says the
treating provider is a non-participating dentist. The Plan also says that you must use network providers to
receive dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit when they are received OON. The Plan also confirmed that when you
contacted the Plan regarding coverage for a periodontist, you were advised a pre-authorization was required
prior to receiving the service. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation provided on January 22, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with neck arthritis and degenerative disc disease status post surgery 7/22/2020. Hospital course has included pain management. Hemodynamics are stable. The enrollee is non-toxic. Neutral spine precautions are in place. Overall, is moderate assist for care. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management,wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.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.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 6, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation
did not include a physician order or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
The file shows that a chronic care management profile was provided. We find that the lab services at issue not
supported in the medical record. The records do not show that the testing was individualized to identify specific
non-prescribed medications or illicit substances. This testing is not covered for screening purposes. The records
do not show that a blood sample was collected to test for carbamazepine, levetiracetam, topiramate, digoxin,
clozapine, or haloperidol. Based on this information, we decided that Medicare rules for coverage have not
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 6,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Hymovis injection.You asked the Plan to pre-approveHymovis. Yousay that your shoulder is painful.The Plan denied your request. The Plan says supporting evidence for viscosupplementation of the shoulder is unconvincing.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Hymovis. Our physician reviewer found that you have left shoulder pain due to advanced osteoarthritis of the shoulder. The enrollee has received 2 cortisone injections in the past and has gotten some temporary pain relief. X-rays of the left shoulder reveal advanced glenohumeral osteoarthritis. According to The American Academy of Orthopedic Surgeons and Medicare guidelines, viscosupplementation of the knee is supported when the enrollee has failed to respond to conservative non-pharmacologic therapy or simple analgesics. However, injection of the shoulder is not supported. Therefore,  viscosupplementation for osteoarthritis of the shoulder 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 Hymovis have not been met.Therefore, we decided that the Plan does not have to pre-approvea Hymovis injection.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services (HCPCS G0483) provided to the enrollee on July
23, 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 that Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22
or more drug class(es), including metabolite(s) if performed."
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 services. Our reviewers says that the
services at issue in this case were supported by the medical records. Our physician reviewer found there is a
signed statement from the provider, itemizing the tests to be ordered, and acknowledging the codes, and the
billing for the codes.
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 services have been met. Therefore, we decided that the Plan has to pay for
drug testing services (HCPCS G0483) provided to the enrollee on July 23, 2019.
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 pay forthe acute inpatient hospital care provided from January 30, 2020 through February 4, 2020.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 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 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 based on the documentation provided, it is my opinion that this hospitalization does not qualify for inpatient payment under the two-midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital would be required. The emergency department (ED) evaluation showed no life/limb threatening condition(s). The enrollee was declared stable for discharge after one midnight of care. Time spent waiting to be returned to the nursing home does not fulfill the medical necessity requirement of the two-midnightrule. 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 January 30, 2020 through February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COSENTYX Pen.
You asked the Plan to pre-approve COSENTYX Pen. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve COSENTYX Pen.
Benefits for COSENTYX Pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted to acute care on 7/7/20 for the treatment of altered mental status, status post repeated falls, generalized weakness, and noted pulmonary lesion. He had a Na+ level of 107 and CT head showed age-related volume loss. Management included antibiotics and hypertonic saline. Now, the enrollee is improving and non-toxic. Diet is regular. He is weak, and moderate/maximum for all cares, mostly. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 need the requested shower chair because you have neuropathy which makes it hard to stand. You say that you are afraid of falling down and causing further injuries or complications to yourself. You asked the Plan to reconsider their denial because you say that you need the shower chair to assist you. 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.