Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical implant placement provided on March 11, 2020.
You asked the Plan to pay for the surgical implant placement. You say that an identical claim was approved.
You say that payment should be made. The Plan denied your request. The Plan says the service is not a covered
benefit.
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 for the
surgical implant placement provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that these are necessary for you.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
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 the enrollee is unable to do three hours a day of therapy.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 documentation does not support that the complexity of the patient's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally stable, and does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While he may well benefit from continuing physical therapy and occupational therapy, the documentation does not support a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. It is not clear that the enrollee 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe abdomen x-ray provided on March 10, 2020.You asked the Plan to pay forthe abdomen x-ray. You say that the enrollee had multiple exams on this date of service.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe abdomen x-ray provided on March 10, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 1, 2019.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records signed by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 23, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on June 6, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on June 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical-level inpatient care provided from November 30, 2019 to December 3, 2019.You asked the Plan to pay forcritical-level inpatient care. You say that this was medically necessary.The Plan denied your request. The Plan says only acute-level care was warranted.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 critical-level inpatient care. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating intensive care unit (ICU) level of care services after the emergency room evaluation. he enrollee was hemodynamically stable and did not require vasopressor therapy. He had no evidence of respiratory compromise and required no hemodynamic monitoring. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of critical-level inpatient care have not been met.Therefore, we decided that the Plan does not have to pay forcritical-level inpatient care provided from November 30, 2019 to December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for thewig provided on January 15, 2020.You asked the Plan to reimburse you for the wig. The Plan denied your request. The Plan says the Plan will only reimburse members for wigs due to hair loss from cancer.Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.The contract with the Plan says that wigs are covered for members who experience hair loss due to treatment for cancer.We looked at the file, the Medicare rules and the Plan rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is non-covered by Medicare. The file shows that the Plan does offer a benefit which would provide coverage for a wigfor enrollees with hair loss due to treatment for cancer. You do not have hair loss due to treatment for cancer. Therefore, we decided that the Plan does not have to reimburse you for thewig provided on January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (71250, 74176).You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the enrollee's abdominal exam is completely normal and there are no significant lab abnormalities except for elevated inflammatory markers. Computed tomography (CT) of the abdomen and pelvis is a diagnostic imaging test used to help detect diseases of the small bowel, colon and other internal organs and is often used to determine the cause of unexplained pain. In this case there is no specific clinical rationale for the requested CT scan of the abdomen/pelvis.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (71250, 74176).
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 admission to an IRF 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 a history of dementia and who was recently treated for fever and changes in mental status, possible pneumonia testing positive for COVID-19 now testing negative, and right lower extremity cellulitis. The enrollee responded to IV fluids and antibiotics. Now, hemodynamics are stable and the enrollee is medically stable, afebrile, and non-toxic. The functional status is minimal assist for transfers and moderate/maximum assist for activities of daily living. 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 memberis anywhere from minimal to maximum 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 Guardant360 panel rendered on February 22, 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 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on April 30, 2020.You asked the Plan to pay for the laboratory 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 laboratory services.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 laboratory services provided on April 30, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea for the enrollee.
You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your
request. The Plan says that they did not receive documentation supporting the medical necessity for a step
therapy exception.
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 to pre-approve Eylea. Our reviewer says that Eylea is
not medically reasonable and necessary for the enrollee in this case. The Plan requires a trial of bevacizumab
before they will approve the requested drug. There is no documentation provided indicating the patient tried
and failed the required bevacizumab. There is no documentation indicating that bevacizumab 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 Eylea.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve Eylea for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab tests provided on May 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab tests. 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 the member's primary care physician did not refer 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 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 forlab tests provided on May 1, 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 services provided on October 8, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee has been receiving IRF
care after a fall. From a nursing perspective, the enrollee received oral medications and insulin. This included
warfarin which was dose adjusted. The enrollee had stable vital signs. Her lungs were clear. Regarding
rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital.
The enrollee was at a moderate assist level for functional mobility. The enrollee required varying assist with
activities of daily living. She had mild cognitive deficits.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs.
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea single level(L3-4) lumbar laminectomy.You asked the Plan to pre-approvea single level (L3-4) lumbar laminectomy. You say that the requested single level (L3-4) lumbar laminectomy is medically necessary. The Plan denied your request. The Plan says the requested single level (L3-4) lumbar laminectomy is 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 reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a single level (L3-4) lumbar laminectomy. Our reviewer says that the requested single level (L3-4) lumbar laminectomy is not medically necessary. Our physician reviewer found the enrollee is with low back and leg pain. There is no documentation of a correlation between exam findings and imaging showing severe nerve root compression in the lumbar spine. Criteria for decompression surgery have not been met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a single level (L3-4) lumbar laminectomy have not been met.Therefore, we decided that the Plan does not have to pre-approve a single level (L3-4) lumbar laminectomy.