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

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80159, 8016280173, 80177, 80201, 80307, and G0483 provided on February 6, 2020.
You asked the Plan to pay for the laboratory services. 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 80157, 80159, 8016280173, 80177, 80201, 80307, and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 80159, 8016280173, 80177, 80201, 80307, and G0483 provided on February 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is needed to rule out vascular dementia vs Alzheimer's dementia. The Plan denied your request. The Plan says this is nationally not covered outside of clinical trials.
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the NCD for PET scan of the brain expressly provides coverage only in the instances where there is a differential diagnosis of FTD and Alzheimer's disease which does not apply in this case based upon the neurologist's differential diagnosis. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 5, 2019 through November 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided records showed the you were stable and without an acute condition warranting admission status. Further workup and monitoring could have been completed in observation status and arranged as outpatient. There was no expected needs which would have required at least a two-midnight stay at the hospital. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 5, 2019 through November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services received on February 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage.
For that reason, the Plan's coverage rules apply in this case. The Plan covers certain vision services by network providers.
We looked at the file and the Plan's rules. Review of the file shows that you received a routine eye exam/refraction for eyeglasses/contacts. This service is not a covered benefit. In addition, the provider of these services was OON. Based on this information, we decided that the Plan's rules for coverage of these OON services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services received on February 11, 2020 by an out of network (OON) provider.
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 IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for femur fracture. The enrollee's medical conditions are now stable. There are no complicated nursing or wound care needs. There is no documentation that the enrollee requires management three days a week by a rehabilitation physician.The medical record also does not support a need for an intensive rehabilitation therapy program.There also is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.Medicare coverage criteria are not 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.You asked the Plan to pre-approve Truxima. You say that the Truxima is medically necessary for epilepsy treatment.The Plan denied your request. The Plan says this drug is not approve for the requested use.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Truxima. Our reviewer says that Truxima is not medically necessary. Our physician reviewer found The review has determined that the requested use of Tuxima is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have not been met.Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the meningococcal vaccine provided to the enrollee on December 13, 2019.You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered service.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay for the meningococcal vaccine provided to the enrollee on December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
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 the injection. Our reviewer says that the enrollee has not met the step therapy requirements for coverage of the requested Gel-One injection. Our physician reviewer found that the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) likely be less effective and/or likely have adverse effects for the enrollee.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection.
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 cannot move at all and need rehabilitation. The
Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require
physical therapy and occupational therapy, you do not require an intensive inpatient rehabilitation therapy
program. Based on the medical records provided, there is concern that you will not be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing
facility level is more appropriate.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on May 3, 2020.

You asked the Plan to reduce the copayment for the urgent care visit. You say that you went to a walk-in clinic and should only be responsible for a $10 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

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 $60 copayment for covered services to a medical facility or urgent care center per visit. 

You have been asked to pay a $60 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows that the place of service was an urgent care facility.

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 reduce the copayment for the urgent care visit provided on May 3, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277).
You asked the Plan to pre-approve the air mattress. You say that the records provided should support the necessity of the service is dispute. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria.
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 air mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case on 3/17/2020, skin examination findings included no rashes, lesions, ulcerations, induration, nodules, or other abnormalities. There was no provided documentation of an existing skin graft, ulcer, or other indication to justify a specialized air mattress. Therefore, this request for such is not supported, does not meet criteria, and will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 29, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 25, 2020.You asked the Plan to pay for the testing. You say that this should be paid for.The Plan denied your request. The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation) requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on December 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab 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 the referring provider is also out-of-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 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 lab services provided on December 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint intervention.

You asked the Plan to pre-approve facet joint intervention. 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 facet joint intervention 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 facet joint intervention. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has lumbar spondylosis, cervical spondylosis and lumbar radiculopathy. The enrollee has chronic low back pain. The prescriber describes the pain as radiating into superior and anterior bilateral legs with occasional radiation to the enrollee's feet. The documentation does not support that the enrollee satisfies all of the requirements of the LCD. Therefore, the requested services are 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 facet joint intervention have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint intervention.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you had stable vital signs. You received oral medications. You required stand-by assistance/supervision with bed mobility. You required contact guard assistance to minimal assistance for transfers and walking 100 feet with a cane. You required varying assistance with activities of daily living. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral radiofrequency ablation.You asked the Plan to pre-approvethe bilateral radiofrequency ablation. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says the medical records submitted document only 10% relief and the member continues to rate their pain as 6/10.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the bilateral radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records document that the member experienced 50% improvement of pain and improvement in patient specific ADLs that are documented for at least 6 months.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 radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral radiofrequency ablation
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay forlab services (CPT 88360) provided to the enrollee on October 15, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysper review of medical record documents received, the microdissection and the immunohistochemistry services are not supported as being performed separately as only the documentation for the immunohistochemistry service was submitted.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, we have confirmed that CPT code 88360 has a bundled relationship with CPT code 88381 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services (CPT 88360) provided to the enrollee on October 15, 2019