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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 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 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 medical services provided to the enrollee by an out-of-network provider on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on August 29, 2019.You asked the Plan to pay forthese 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 forthe drug testing rendered on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 testing provided on July 9, 2019.
You asked the Plan to pay for the Guardant 360 testing. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 codes 81120, 81121, 81173,81201, 81210, 8123581270, 81272, 81275, 81293, 81310,
81311, 81314, 81321, 81400, 81401, 81402, 81403, and 81404 are not supported in the medical record.
Specifically, this testing provided requires the use of CPT 81479 and the appropriate DEX Z identifier entered
adjacent in the comment narrative field. The claim does not have CPT 81479 billed for these services. Based on
this information, we decided that Medicare rules for coverage of the Guardant 360 testing have not been met.
Therefore, we decided that the Plan does not have to pay for the Guardant 360 testing provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00731) provided on January 28, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the service 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.
In this case, the CPT Code Manual definition of code 00731 is anesthesia for upper gastrointestinal endoscopic
procedures, endoscope introduced proximal to duodenum; not otherwise specified.
We asked our coder 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 anesthesia services. Our reviewer says that CPT code
00731 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation
submitted does not include and anesthesia report to verify the billed services.
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 anesthesia services have not been met. Therefore, we decided that the Plan
does not have to pay for anesthesia services (00731) provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 21, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve longterm acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting. The LTACH will not provide additional services.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 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 he is 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.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening provided on November 19, 2019.
You asked the Plan to pay for the prostate cancer screening. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an inappropriate diagnosis code.
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 G0103 is prostate cancer screening; prostate specific antigen test (psa). We find that CPT code G0103 is not supported in the medical record. Specifically, this code was billed with diagnosis code N40.0 (Enlarged prostate without lower urinary tract symptoms). Screening tests such as this one must be billed with using either a screening (V) code V76.44 (Special screening for malignant neoplasms) or diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate). The claim was not billed with either of the required diagnosis codes. Based on this information, we decided that Medicare rules for coverage of the prostate cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for the prostate cancer screening provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forselective catheter placement (36248) provided on May 13, 2019.You asked the Plan to pay forselective catheter placement. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the operative report does not support the number of units 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 asked our coder 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 selective catheter placement. Our reviewer says that CPT code 36248 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not support the number of units billed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of selective catheter placement have not been met.Therefore, we decided that the Plan does not have to pay forselective catheter placement (36248) provided on May 13, 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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for evaluation of falls. All medical problems are stable and do not require ongoing inpatient management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does have a documented need for physical therapy but the documentation does not support a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral RFA (64635 and 64636)You asked the Plan to pre-approve the bilateral RFA. You say that you would like reconsideration because the member would benefit from the bilateral procedure.The Plan denied your request. The Plan says there is no documentation of 50% relief for 6 months.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 bilateral RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the member had 50% pain relief for 6 months and has no decreased range of motion or pain.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 bilateral RFA have not been met.Therefore, we decided that the Plan does not have to pre-approve bilateral RFA (64635 and 64636)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee orthosis (L1832).You asked the Plan to pre-approvethe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the custom brace is not supported in the records received.The Plan follows Medicare rules. Medicare rules say that there must be a condition or anatomical difference that warrants a custom brace. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided notes support temporary use of a basic standard knee brace to help her shift to more physical therapy. The physical findings did not reveal any condition or specific anatomy which might warrant a custom brace for this clinical situation. Therefore, this request for a custom knee brace isconsidered 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 the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee orthosis (L1832).
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says you can receive the necessary care in another setting.
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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Additionally, you do not require IRF level therapies and your needs can be met at a lower intensity setting. 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: Favorable

We decided that the Plan has to pre-approve use of the Optune tumor treatment field therapy (TTFT) device.
You asked the Plan to pre-approve the Optune TTFT. You say that the enrollee would benefit from use of this device. The Plan denied your request. The Plan says that the criteria for this treatment are not met.
The Plan follows Medicare rules. Medicare rules say that TTFT is covered for enrollees with newly diagnosed GBM when the above referenced 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 pre-approve the Optune TTFT. Our reviewer says that the documentation support that the criteria for the use of this device are met. Our physician reviewer found The documentation in the case file supports that the coverage criteria for TTFT have been met in this case. The enrollee has histologically confirmed (World Health Organization (WHO) grade IV astrocytoma), newly diagnosed, supratentorial GBM, and has received initial treatment with maximal debulking surgery, followed by chemotherapy and radiotherapy. The tumor treatment field therapy is being initiated within 7 weeks from the last dose of concomitant chemotherapy or radiotherapy. The enrollee has no documented progression. The enrollee has a Karnofsky Performance Score (KPS) of 80. The enrollee has been instructed on the use TTFT for an average of 18 hours per day. Based on this information, the criteria are met and the device is considered 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 Optune TTFT have been met. Therefore, we decided that the Plan has to pre-approve use of the Optune tumor treatment field therapy (TTFT) device.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 13, 2020 by an out of network (OON) provider.You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were non-emergent and out-of-state.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 specialist services provided on January 13, 2020 by an out of network (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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office services provided on February 12, 2020.
You asked the Plan to waive the copayment for the specialist office services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 specialist office services provided on February 12, 2020. You are asked to pay a $30 copayment 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 the specialist office services provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 2, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite provided on October 21, 2019.You asked the Plan to pay forthe resin-based composite. You say that the bill you received clearly indicates you received a resin composite cavity filling on upper tooth #5, and not maintenance of gums/bones.The Plan denied your request. The Plan says this service is not a covered benefit by Medicare.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.Therefore, we decided that the Plan does not have to pay forthe resin-based composite provided on October 21, 2019.