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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has multiple medical conditions that require care, and LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee does not require extensive or complex wound care management or skilled nursing for at least 6.5 hours per day. The wound care does not require daily intervention by a physician. There is no documentation that the enrollee will benefit from and improve with LTACH management, and the clinical assessment does not support the expectation of a stay of at least 25 days. The enrollee's medical needs are being med in the current acute setting and the LTACH would provide no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
The Plan must follow Medicare 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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not. medically necessary, reasonable, and appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on June 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 procedure code 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services.
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 physical therapy services rendered on June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021.
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. The rules say that a PC/TC indicator of 8 identifies professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. Billed procedure code 85060 (blood smear interpretation) has a PC/TC indicator of 8. The file shows that the services were not performed in the inpatient setting. 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 laboratory services rendered on February 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are not identifiable daily skilled nursing or therapy needs and an inpatient level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means that admission into a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, carboplatin, and Taxol, represented by HCPCS code(s) J9271, J9045, and J9267.
You asked the Plan to pre-approve Keytruda, carboplatin, and Taxol. You say that the drugs are medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that the drugs are helpful when you've already tried a similar drug and didn't have a positive response.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda, carboplatin, and Taxol. Our reviewer says that this service is not medically necessary. Our physician reviewer found these drugs are not FDA approved for the enrollee's diagnosis and the use is not supported in any of the major drug compendia or clinical research.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, carboplatin, and Taxol have not been met. Specifically, the requested drugs are not approved for the enrollee's diagnosis, and therefore, are not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Keytruda, carboplatin, and Taxol, represented by HCPCS code(s) J9271, J9045, and J9267.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87633) provided July 22, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the test at issue is non-covered.
The Plan must follow Medicare rules. Medicare rules say that tests that include more than 5 viral pathogens are non-covered. We looked at the file and Medicare rules. The test performed tested for more than 5 viral pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87633) provided July 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional breast augmentation.
You asked the Plan to pre-approve additional breast augmentation. 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 cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 additional breast augmentation. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our reviewer found you previously underwent breast augmentation as part of gender reassignment surgery. The record indicates that you are unhappy with the results. The requested surgery is cosmetic in nature and not part of gender reassignment services. Therefore, you do not meet criteria for the requested 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 additional breast augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional breast augmentation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered reasonable and necessary.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (29520) provided February 10, 2021 to March 3, 2021.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services cannot be paid as billed.
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 29520 is not supported in the medical record. Specifically, the claim did not include a required therapy modifier. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (29520) provided February 10, 2021 to March 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on October 1, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be waived because it was an emergency. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 for ambulance services. You have been asked to pay a $250 copayment for the ambulance services. This copayment applies to both emergency and non-emergency ambulance 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 ambulance services you received on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on August 20, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on August 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had at an outpatient hospital facility on July 8, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you should be able to have a free ultrasound each year. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $100 copayment for ultrasounds. You have been asked to pay a $100 copayment for the ultrasound. 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 ultrasound you had at an outpatient hospital facility on July 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mirena IUD (intrauterine device), 3 years.
You asked the Plan to pre-approve Mirena. You say that the IUD was initially placed for contraception. You say that it is indicated to prevent endometrial hyperplasia. You say that the IUD is the enrollee best option or hormonal imbalance issues. you also say that the enrollee has been on Mirena for 10 years successfully. The Plan denied your request. The Plan says contraceptive devices and insertion and removal of contraceptive devices are not covered (such as an IUD).
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary.
Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-approve Mirena IUD (intrauterine device), 3 years.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (V2788) received from February 4, 2021 to February 19, 2021.
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 is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens (V2788) received from February 4, 2021 to February 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the hydration therapy rendered on April 30, 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 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 states that the services were rendered in the state of New Jersey and that Local Coverage Determination (LCD) L34960 is binding; however, there is no documentation in the file to support that the services were rendered in New Jersey. The claim dispute form lists a National Provider Identifier (NPI) number that is listed as located in New York. The Plan has not provided any further documentation or rules to support that the services are not payable. Therefore, we decided that the Plan has to pay for the hydration therapy rendered on April 30, 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 pre-approve BRCA1 testing.
You asked the Plan to pre-approve BRCA1 testing. 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 follows Medicare rules. Medicare rules say that BRCA testing is only covered for certain indications.
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 BRCA1 testing. Our reviewer says that the documentation does not support that the requested testing is medically reasonable or necessary. Our physician reviewer found you have no personal history of cancer and you have a sister and a niece who have no history of cancer but tested positive for BRIP1. Based on the above, the criteria for BRCA testing is not met and this request for such is not supported and will be considered not 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 BRCA1 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided on October 15, 2020.
You asked the Plan to pre-approve foot orthotics. You say that you have pain in your arches. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out of network (OON) provider on December 23, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out of network (OON) provider on December 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayments charged for outpatient mental health care provided from December 10, 2020, to December 31, 2020.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the claim submitted by your provider and the Plan contract agreement.
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 $10 copayment for each outpatient mental health visit. 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 $10 copayments charged for outpatient mental health care provided from December 10, 2020, to December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on December 3, 2020.
You asked the Plan to waive the coinsurance for the genetic testing. You say that you would like the Plan to reduce this patient's cost sharing and pay more towards the claim. The Plan denied your request. The Plan says this coinsurance was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for molecular and predisposed genetic testing. The enrollee has been asked to pay 20% coinsurance for the genetic testing. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing provided on December 3, 2020.