Persius/hicric huggingface dataset:
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's ongoing skilled therapy and nursing needs can be provided at a lower 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The hospital course complicated by sepsis and aspiration pneumonia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services rendered on March 23, 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 were experimental/investigational in nature.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 skilled
services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the records do not support that the enrollee required therapeutic
interventions for cognitive function for the date of service at issue. The records are not considered under
accepted standards of medical practice to be a specific and effective treatment for the patient's condition. The
enrollee has poor short term memory, moderate dementia, and lost her prior diagram for her home exercise
program. There is no evidence that the services would alter the course of her condition or improve her
functioning. She had limited carryover from prior therapy, which does not support the need for the services.
The services were 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 therapy services rendered on March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammography (CPT 77067).

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 there is a gender inconsistency with the procedure 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 77067 is "screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed."

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found Medicare covers as many diagnostic mammograms a doctor considers necessary, and are available for both male and female, if a person has a history of breast cancer. However, Medicare does not cover screening mammograms for men. Patient has a personal history of left breast cancer, invasive ductal carcinoma. A diagnostic mammogram would be appropriate to report 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 services have not been met. Therefore, we decided that the Plan does not have to pay for a screening mammography (CPT 77067) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or the member's primary care physician.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (72131).

You asked the Plan to pay for a CT scan. You say that this code is not limited to a specific POS. The Plan denied your request. The Plan says this was not billed with the correct POS code.

The Plan must follow Medicare rules. Medicare rules say that when a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.

We looked at the file and Medicare rules. The record shows that the enrollee was registered as an inpatient at the time this service was rendered, but this service was billed with POS code 22 for outpatient hospital. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (72131).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 24, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on September 24, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on April 16, 2019, by a non-participating provider.

You asked the Plan to pay for the medical services. You say that you depend on the facility for timely notification of the enrollee's health insurance coverage and you did not receive that proper notice. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the medical services was not filed until September 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on April 16, 2019, by a non-participating provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by a non-participating provider.

You asked the Plan to pay for the medical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a
network provider and the services were not urgent or emergent, nor were they approved in advance.

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 had network providers
available who could have provided 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 the medical services provided to the enrollee by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 11, 2020.

You asked the Plan to pay for the psychotherapy 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 psychotherapy 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 psychotherapy services provided on September 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (TDAP) (90715) and immunization administration (90471) provided on October 21, 2020.

You asked the Plan to pay for TDAP vaccine and administration. You say that the service should be covered. The Plan denied your request. The Plan says the vaccine was administered as a preventative measure.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP vaccine and administration. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to TDAP vaccine and administration. Specifically, the vaccine was administered as a preventative measure, not due to an injury. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine (TDAP) (90715) and immunization administration (90471) provided on October 21, 2020.

Benefits for TDAP vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2950).

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 D2950 is not listed in the schedule of benefits, and was not pre-authorized by the plan.

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 dental services (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found it is not medically reasonable and necessary to
provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." You
do not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on October 8, 2020.

You asked the Plan to pay for gingival irrigation and medicaments. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered on your benefit plan.

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. Specifically, the services are not listed in the Plan's benefit chart. This means the services are not covered under your benefit plan. Therefore, we decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gym equipment (A9300).

You asked the Plan to pay for gym equipment. You say that the item should be covered. The Plan denied your
request. The Plan says due to the coronavirus, the Plan is allowing your $300 health club membership to be
used towards the purchase of gym equipment. However, the effective date for this change is October 1, 2020,
to December 31, 2020. Only purchases made during this period and submitted for reimbursement by the
deadline will be reimbursed, any purchase made prior to October 1, 2020, does not qualify.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $300 towards
health club memberships a year. However, due to coronavirus, the Plan is allowing that $300 to be used
towards the purchase of gym equipment.

The Plan's rules for coverage of gym benefits have not been met because you purchased your gym equipment
prior to October 1, 2020. This means the item is not covered under your benefit plan. Therefore, we decided
that the Plan does not have to pay for gym equipment (A9300)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on October 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and paid. 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. The Plan says that these services could have been provided in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 had network providers available who could have provided 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 radiology services provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you have therapy visits your need transportation to. The Plan denied your request. The Plan says that you have used all 24 one-way non-emergent transportation trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ConfirmMDX Epigenic Molecular Assay (81551).

You asked the Plan to pay for the testing. You say that you would like reconsideration because this service is a Medicare covered benefit. The Plan denied your request. The Plan says that the member does not have persistent or elevated cancer risk factors and the member is not being considered for a repeat biopsy.

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 pay for the testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary and meet LCD criteria in this case. Our physician reviewer found the member is aged 40 to 85 years old and has undergone a previous cancer-negative prostate biopsy within 24 months and is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. The previous negative prostate biopsy collected a minimum of 8 tissue cores (but not have received a saturation biopsy of > 24 tissue cores) and remaining FFPE tissue from all cores is available for testing. The minimum tissue volume criteria of 20 microns of prostate biopsy core tissue is available. The previous biopsy histology does not include a prior diagnosis of prostate cancer or cellular atypia suspicious for cancer. The member is not being managed by active surveillance for low stage prostate cancer. The tissue was extracted using standard patterned biopsy core extraction. The member has not been previously tested by ConfirmMDx from the same biopsy samples or similar molecular test.

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 testing have been met. Therefore, we decided that the Plan has to pay for the ConfirmMDX Epigenic Molecular Assay (81551).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab and Paclitaxel.

You asked the Plan to pre-approve Nivolumab and Paclitaxel. You say that the drugs are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 Nivolumab and Paclitaxel. Our reviewer says that the requested drugs are not medically necessary. Our physician reviewer found there is no compendia basis or literature support for this combination of drugs in metastatic adrenal cancer. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab and Paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab and Paclitaxel.