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

We decided that the Plan does not have to pre-approve a follow-up colonoscopy.

You asked the Plan to pre-approve a follow-up colonoscopy (45378). You say that your doctor wants you to have another colonoscopy to see if all the cancer is out. The Plan denied your request. The Plan says typically the initial follow-up is a year.

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 a follow-up colonoscopy (45378). Our reviewer says that a follow-up colonoscopy is not medically reasonable and necessary. Our physician reviewer found per the National Comprehensive Cancer Network (NCCN) Guidelines colonoscopy for stage II colon cancer should be in 1 year. This patient's last colonoscopy was December of 2020. 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 a follow-up colonoscopy (45378) have not been met. Therefore, we decided that the Plan does not have to pre-approve a follow-up colonoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided July 23, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 code G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the medical records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided July 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

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 pre-approve ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had extensive prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve PET scan. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this test can be performed by an in-network provider.

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. 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 Positron Emission Tomography (PET) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on February 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that no one could help with your medical condition. The Plan denied your request. The Plan says the claim was processed correctly.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on February 17, 2021 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.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF instead of a lower level of care. 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 in the Medicare rules section. 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. While the
enrollee does require physical therapy and occupational therapy, the record shows the enrollee does not require an intensive inpatient rehabilitation therapy program. Case at the skilled nursing facility (SNF) level appears to be 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 15, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says these items were not medically necessary based on the documentation.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules.

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 knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found that 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 insufficient credible objective documentation of joint laxity. In addition, 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 15, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service 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 in the Medicare rules section 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 the service is medically necessary. Our physician reviewer found you do have documented skilled therapy needs. You are functioning below your baseline and have not yet reached a new plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition. 

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the wound care services provided on January 14, 2021, to January 28, 2021.
You asked the Plan to waive the copay for the services provided. You say that you do not agree with the type of service being billed. The Plan denied your request. The Plan says the claims processed correctly.
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 $350 copay for outpatient surgery, including services provided at an outpatient hospital facility.
The file shows that you received debridement services at an outpatient hospital facility. The services are considered surgical services. You have been asked to pay a $350 copay for the services provided.
The file shows that you received debridement services at an outpatient hospital facility. You were charged a $100.03 copay. Because the amount was less than the $350 copay, you were charged a lesser amount.
The file shows that you received strapping of Unna boot services at an outpatient hospital facility. The services are considered surgical services. You were charged a $184.85 copay. Because the amount is less than the $350 copay, you were charged the lesser amount.
The services fall within the outpatient surgery 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 copay for the wound care services provided on January 14, 2021, to January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the breast prosthesis provided on February 11, 2021.
You asked the Plan to waive the cost share for the provided device. You say that the claim should be reprocessed with no enrollee liability. The Plan denied your request. The Plan says the claim processed correctly.
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 20% coinsurance for prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance for the breast prosthesis. The item falls within the prosthetic devices and related supplies 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 cost share for the breast prosthesis provided on February 11, 2021.
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 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 in the Medicare rules section. 

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 and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 

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 pay for the emergency department visit for the evaluation and management of a patient (99284) provided February 29, 2020.

You asked the Plan to pay for the emergency department visit for the evaluation and management of a patient. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was filed after the deadline had passed.

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 emergency department visit for the evaluation and management of a patient was not filed until April 2, 2021. 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 emergency department visit for the evaluation and management of a patient (99284) provided February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 15, 2020.

You asked the Plan to pay for the orthosis. You say that the records prove necessity of the treatment. The Plan denied your request. The Plan says the reasonableness of the provided equipment has not been established.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that the orthosis at issue may have been ordered by an unsolicited outreach telephone call to the enrollee. This request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is not medically accepted or supported.
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 Keytruda. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the record indicates that the enrollee has clinical stage IIa or IIb squamous cell lung cancer. The enrollee was previously treated with chemotherapy, which was stopped due to poor tolerance, and also received radiation initially followed by additional radiation when the enrollee developed a new lesion. The enrollee now has increased left lower lobe mass. PD-L1 determination has not been performed. The Medicare approved cancer compendia do not support the use of the requested agent in the enrollee's clinical scenario. No PD-L1 testing is available. Any
recommendations graded as 2b are not considered supportive citations. No literature from Medicare approved cancer journals was submitted for review in support of the request. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the telephone evaluation and management service
(99443) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the telephone evaluation and management service. You say that you would
like reconsideration because this is the provider that performed your surgery and needs to be the one to go over
your approved magnetic resonance imaging results with you. The Plan denied your request. The Plan says a
neurosurgeon who is part of your primary care physician's medical group can follow-up on your surgery.

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 provider at issue in this case is not a network provider with the Plan. 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 telephone evaluation and management service. Our reviewer says that
the requested service is not medically necessary and reasonable, as defined by Medicare rules, for your specific
clinical scenario. Our physician reviewer found the Plan has indicated that an in-network neurosurgeon can see you and if deemed necessary a referral to the original surgeon can be made. You are not receiving active treatment 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 telephone evaluation and management service have not been met. 

The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the telephone evaluation and management service. Therefore, we decided that the Plan does not have to pre-approve the telephone evaluation and management service (99443) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided March 11, 2021.

You asked the Plan to pay for the x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for this service was exhausted at the time the service was rendered.

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 record shows two sets of intraoral x-rays were already covered for the calendar year. The benefit for intraoral x-rays was exhausted at the time the service was provided. Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided March 11, 2021.