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

We decided that the Plan does not have to pre-approve MSH6 genetic testing for the enrollee. 

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of widespread metastatic Malignant neoplasm of the endometrium. The enrollee has had Foundation One genetic testing. An alteration in the MSH6 gene was found, which is heterozygous. The enrollee has had Foundation One genetic testing. It has not been clearly demonstrated that the requested additional genetic testing is clinically useful in this enrollee's management. Testing which has no proven relation to the management of a medical condition for the health of an enrollee is not a covered Medicare benefit.

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve MSH6 genetic testing for the enrollee. 

The Local Coverage Determinations (LCDs) referenced by the Plan do not provide coverage criteria for MSH6 genetic testing and were not used in the MAXIMUS determination.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forlow osmolarcontrast material, 300-399 mg/ml iodine concentration, per ml (Q9967), routine venipuncture (36415), comprehensive metabolic panel (80053), computed tomography (CT) scan of the thorax (71260), CT scan of the abdomen and pelvis (74177), complete blood count (85025), and a hospital outpatient clinic visit (G0463) provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forlow osmolar contrast material, routine venipuncture, comprehensive metabolic panel, CT scan of the thorax, CT scan of the abdomen and pelvis, complete blood count, and a hospital outpatient clinic visit. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says non-emergency services provided by a non-contracted provider are not covered when a contracted provider is able to perform the services.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 payfor 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 forlow osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (Q9967), routine venipuncture (36415), comprehensive metabolic panel (80053), computed tomography (CT) scan of the thorax (71260), CT scan of the abdomen and pelvis (74177), complete blood count (85025), and a hospital outpatient clinic visit (G0463) provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 18, 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 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 to the enrollee on July 18,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder, elbow, wrist, hand orthotic (SEWHO) (L3960)
provided May 13, 2019.
You asked the Plan to pay for the SEWHO. You say that the records should support the necessity of the service
in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
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 SEWHO. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the prescription form documented a diagnosis of bilateral shoulder osteoarthritis. However, the
primary care physician clinical records do not document a shoulder complaint, shoulder physical exam,
shoulder functional deficit, shoulder osteoarthritis diagnosis, or specific rationale to support shoulder bracing
for this enrollee. There is no evidence that supports the medical necessity of these braces for the or treatment of
illness or injury or to improve the functioning of a malformed body member.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SEWHO have not been met. Therefore, we decided that the Plan does not
have to pay for the shoulder, elbow, wrist, hand orthotic (SEWHO) (L3960) provided May 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the abdomen (74018) provided July 18, 2019.
You asked the Plan to pay for the X-ray. You say that services were medically necessary and properly billed. The Plan denied your request. The Plan says the claim was submitted with the wrong place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 74018 is not supported in the medical record. Specifically, the claim notes the service was performed in the outpatient setting, but the record shows the enrollee was an inpatient at the time the service was provided. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met. Therefore, we decided that the Plan does not have to pay for an X-ray of the abdomen (74018) provided July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with suspension sleeve rendered to enrollee on September 13, 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 the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee's chief complaint was bilateral knee pain. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The knee orthosis and suspension sleeve were therefore 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 these services have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthosis with suspension sleeve rendered to enrollee on September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital facility services
provided from September 4, 2019 through September 11, 2019.
You asked the Plan to waive the copayment for the services. You say that you are asking the Plan to reduce the
copay for the outpatient services that you received in the facility because in the past you have not had to pay
$250 before. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019
EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received outpatient hospital facility services provided from September 4, 2019
through September 11, 2019. The Medicare-allowed amount for the services is less than the set $250
copayment; therefore, you have been asked to pay the lesser amount of $221.34 for the services. 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 outpatient hospital facility services provided from September 4, 2019
through September 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-emergency air ambulance transportation.
You asked the Plan to pre-approve the air ambulance transportation. You say that you were injured while you were out of state and is trying to get home. You have been approved SNF admission in your home state of Florida. The Plan denied your request. The Plan says non-emergency air ambulance from Boston, MA to Gainesville, FL is not medically necessary as it is not to the closest facility that can provide the necessary medical care.
The plan follows Medicare rules. The rules say that Medicare pays for air or ground ambulance services only if the enrollee's medical condition is such that transportation by means other than an ambulance would not be appropriate. The rules say that Medicare only pays for air or ground transport to the nearest facility that meets the enrollee's medical needs if the enrollee cannot be treated by the originating facility. The records show the enrollee is being successfully treated at their current location. There is no indication this facility could not meet the enrollee's medical needs, nor is this the closest location able to provide services. Based on this information, we decided that Medicare rules for coverage of the air ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-emergency air ambulance transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on January 30, 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that modifier "-58" was established to facilitate billing of
staged or related surgical procedures done during the postoperative period of the first procedure.
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 36589-59. This
procedure was related to a previous surgical procedure and is not payable unless billed with the -58 modifier.
Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on January 30,
2019.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly contact guard assist (CGA)/standby assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 topre-approve Procrit. Our reviewer says that Procrit is not medically reasonable and necessary for the enrollee in this case. The enrollee has anemia related to chronic kidney disease. The Plan requires a trial of Retacrit before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Procrit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Procrit for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued private duty nursing services.You asked the Planto pre-approvethe continued private duty nursing care. You say that the enrollee remains in need of private duty nursing due to her medical condition.The Plandenied your request. The Plansaysthis service is not covered by Medicare and the Plan has already approved payment of the maximum benefit allowed under the supplemental coverage.The Plan must follow Medicare rules. Medicare rules say that private duty nursing is not covered. The Plan offers a supplemental benefit for this service which goes beyond the Medicare benefit. As such, the Plan's rules apply.In this case, the Plan only offers up to $5000 per year to be applied toward private duty nursing services. The Plan has provided documentation that the total amount of $5000 has already been approved and that this benefit is now exhausted.Therefore, we decided that the Plandoes not haveto pre-approvecontinued private duty nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.The Plan must followMedicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, ongoing care needs include respiratory support with oxygen supplementation, telemetry, intravenous antibiotics, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network cost share exception for out-of-network services.You asked the Plan to pre-approve an in-network exception. The Plan denied your request. The Plan says if you choose to receive care outside of the plan's network, the services will be payable in accordance to your point of service benefit.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 saysthat you must pay 20% of the total cost for point of services. You have been asked to pay 20% of the total cost for inpatient hospital services at an out-of-network facility. The services fall within the point of servicebenefit 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 pre-approvean in-network cost share exception for out-of-network services..
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a lower spine fusion procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication for a 3-level lumbar fusion based on the documentation provided.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with a fifteen-year history of persistent low back and buttocks pain. Pain is worse with sitting, standing, walking and bending. Significant functional impairment was documented. Clinical exam findings have documented reflex changes consistent with imaging evidence of moderate spinal canal stenosis at L2/3, moderate to severe spinal canal stenosis and bilateral neuroforaminal narrowing at L3/4, and severe spinal canal stenosis and moderate to severe bilateral neuroforaminal narrowing at L4/5. At L3/4, the spine surgeon has documented 5 mm of spondylolisthesis increased to 9 mm on flexion/extension films. At L4/5, the spine surgeon has documented 9 mm of spondylolisthesis increased to 15 mm on flexion/extension films. He has reported stenosis at the L2/3 level as severe. She has failed long-term reasonable and comprehensive conservative treatment with residual and worsening symptoms. Under consideration is a request for L2/3, L3/4, and L4/5 anterolateral fusion with posterior fixation. Current evidence based medical literature would support the surgical request on the basis of persistent pain, functional limitations, failed conservative treatment, neurologic deficit, imaging findings of moderate to severe multifactorial stenosis, and segmental instability at the L3/4 and L4/5 levels. There is plausible need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, this request for lumbar fusion surgery is medically reasonable and 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve a lower spine fusion procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient behavioral health admission for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee could be treated at a partial hospitalization program.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 20, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any physical behaviors or aggression but had verbal anger and being cooperative and compliant. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient behavioral health admission for the enrollee.