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

We decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on March 10, 2020.You asked the Plan to pay forthe CGP testing. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 CGP testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on March 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe non-emergency stretcher van transportation (T2005).You asked the Plan to pre-approvestretcher van transportation. You say that you would like to appeal the denial for coverage for the stretcher van transportation.The Plan denied your request. The Plan says this is not covered under the plan benefits.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 health Plan contract specifically says that transportation by stretcher (for members who require a stretcher) is not a covered benefit. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approvethe non-emergency stretcher van transportation (T2005).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483 and CPT 80307) provided to the enrollee on May 21, 2019.
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 the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed CPT 80307: Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 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 the submitted medical records do not contain any evidence supporting an established physician patient relationship. There is no clinical information indicating rationale for testing or indicating that the results of testing were used to manage the enrollee's medical 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483 and CPT 80307) provided to the enrollee on May 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and sleeve (L2397) provided February
24, 2020.
You asked the Plan to pay for the orthosis. You say that you are submitting supporting documentation for the
medically necessary supplies dispensed pursuant to physician orders, which were received by the enrollee. The
Plan denied your request. The Plan says the services are not supported in the medical records. The billed supply
code cannot be verified.
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 the orthosis. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found The documentation in the case file does not support that the requested knee orthosis and sleeve
were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria
established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the
enrollee's knee, and there is no credible objective documentation of joint laxity. The item coded L2397 (sleeve)
is not separately payable when the base item is not covered.
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 pay for knee orthosis (L1833) and sleeve (L2397) provided February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided from February 12, 2020 through February 14, 2020.You asked the Plan to pay for inpatient mental health care. You say that the stay was necessary.The Plan denied your request. The Plan says the stay is not necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Patient was treated under an individualized treatment plan found in the record. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 12, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided from February 12, 2020 through February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alimta/Pemetrexed for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this must be used as initial treatment when given in combination with pembrolizumab
and platinum chemotherapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found for patients in whom
progression has occurred on or after available targeted therapies, combination chemotherapy, and
immunotherapy, the appropriate next option is single-agent chemotherapy, if patients remain candidates for
treatment. This patient remains a candidate for treatment and single agent pememtrexed (alimta) would be
appropriate but not in combination with carboplatin. The service is 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Alimta/Pemetrexed for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe hearing aids services provided on December 13, 2019 and January 20, 2020.You asked the Plan to pay forthe hearing aid services. You say that your Primary Care Physician set up your appointment for your hearing aids and you feel you should be reimbursed the Plan benefit allowed amount.The Plandenied your request. The Plan says that the services are not covered.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is providedthat the services will not be covered. The Plan follows these rules.You were referred for the hearing aid services by a contract provider. The file does not show that the Plan provided notice that the hearing aid services would not be covered. Under Medicare rules, this means the hearing aid services is considered approved by the Plan. Furthermore, it is the plan's responsibility to show that its decision to deny coverage is correct. Documents or information of plan directed care from a plan provider areconsidered to be within the control of the plan. Enrollees should not be penalized for a plan's failure to obtain information that is within the plan's control, which in this case would be not getting confirmation from the Plan provider that they referredthe enrollee to the non-contracted provider.Therefore, we decided that the Plan has to pay forthe hearing aids services provided on December 13, 2019 and January 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp (J0881).You asked the Plan to pre-approvethe Aranesp. The Plan denied your request. The Plan says you told the Plan the enrollee can use Retacrit. The Plan also says that the drug Retacrit has been approved for six months.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 Aranesp. Our reviewer says that Aranesp does not meet the Plan's coverage criteria. Our physician reviewer found the health plan requires that Retacrit be used first. There is no evidence that the enrollee is allergic to or intolerant of Retacrit. Our reviewer found that there is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to whyRetacrit would not be expected to be safe and effective for the enrollee. Our physician reviewer also found that the requested Aranesp is not shown to be currently medically necessary and reasonable 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 Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp (J0881).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with an out-of-network provider does not meet medical necessity guidelines.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs a higher level of care and assistance. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or nursing services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs and her lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee required maximum to total assist with functional mobility and activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal scaling and root planing (D4342) provided on February 3, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.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 service provided is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal scaling and root planing (D4342) provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lifeline emergency alert system. You asked the Plan to pre-approve a lifeline emergency alert system. You say that you need an alert system because you have fallen and there was no one to help you. The Plan denied your request. The Plan says lifeline services are statutorily excluded from Medicare coverage. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. A life alert system is an emergency communications system which does not serve a diagnostic or therapeutic purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve a lifeline emergency alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a scooter. You say that a power wheelchair does not fit by your doors and is
not able to get around your house. The Plan denied your request. The Plan says a power wheelchair is not the
most appropriate mobility device for you at this time.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the enrollee cannot
adequately maneuver the device in the home.
The assessment shows that a scooter is not appropriate for your home because of the larger turning radius in
your small home. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that the services you need are not available in-network. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 has a tertiary-level provider that is able to provide the same level of care as the requested provider. The Plan confirmed that the in-network provider is able to provide the services you need. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 13, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were seen by the provider during a hospital stay. You say you have never been charged for an office visit while being treated in the hospital. 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 $40 copayment for each covered specialist office visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visit" benefit category. 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 visit provided on February 13, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that 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 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 enrollee was admitted to the hospital with COVID-19 infection, sepsis, and respiratory failure. The enrollee requires nasal prongs oxygen at rest, and a nonrebreather with mobility. 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.