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

We decided that the Plan has to pay forcoronary artery disease (CAD) gene expression profile testing provided on March 11, 2020.You asked the Plan to pay forCAD testing. You say that Medicare does cover this procedure, and the diagnosis codes justify medical necessity for this testing.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.The Plan must follow Medicare rules. Medicare rules say that testing code 81493 is covered when billed with diagnosis codes R42 and I10. We looked at the file and Medicare rules. The Plan denied payment on the basis that this testing is not a Medicare benefit for the diagnosis codes billed. However, this testing is a Medicare covered benefit for the diagnosis codes billed. Based on this information, we decided that Medicare rules for coverage of CAD testing have been met.Therefore, we decided that the Plan has to pay forcoronary artery disease (CAD) gene expression profile testing provided on March 11, 2020.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services for an eye exam provided on February 17, 2020.You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says there is a $45 copayment for vision care provided by a specialist.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 $45 copayment for In-Network Medicare Covered Vision Services-Specialist's Office services. You have been asked to pay $45 copayment for the physician's services. The physician's services falls within the In-Network Medicare Covered Vision Services-Specialist's Office 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 physician's services for an eye exam provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine (72148) and an MRI of the pelvis (72196).You asked the Plan to pre-approvean MRI of the lumbar spine and an MRI of the pelvis. 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. Medicare rules say that MRIs 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 an MRI of the lumbar spine and an MRI of the pelvis. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no specific clinical rationale for the requested MRI of the lumbar spine and pelvis. There are no focal neurological deficits on exam and the x-rays of lumbar spine and pelvis demonstrate an L1 compression fracture with normal pelvis and hips. There is no indication that further advanced imaging will change management. The review has determined that the requested MRI studies are not medically reasonable or 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 an MRI of the lumbar spine and an MRI of the pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine (72148) and an MRI of the pelvis (72196).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear stress test provided by a participating provider on February 11, 2020.You asked the Plan to waive the copayment for a nuclear stress test. You say that you were not expecting such a high copayment. The Plan denied your request. The Plan says the correct copayment has been applied.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 $250 copayment for outpatient diagnostic tests/nuclear medicine radiological services. You have been asked to pay a $250 copayment for a nuclear stress test. A nuclear stress test falls within the outpatient diagnostic tests/nuclear medicine radiological services benefit category. This means that you have been asked to paythe 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 a nuclear stress test provided by a participating provider on February 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on February 11, 2020.You asked the Plan to waive the copayment forthe ambulance ride. You say that you cannot afford the 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 $250 copayment for each one-way Medicare-covered ground trip. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the ambulance ride.You have been asked to pay a $218.23 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Services" 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 forthe ambulance ride provided on February 11, 2020.
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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora practitioner visit provided by an out-of-network provider on March 2, 2020.You asked the Plan to pay forpractitioner visit. You say that the enrollee was seen by your provider at the request of the nursing home.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay fora practitioner visit provided by an out-of-network provider on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on February 10,
2020 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this was medically necessary. The Plan
denied your request. The Plan says this was not authorized.
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 the nursing facility care (99308) provided on
February 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on January 10, 2020.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 submitted panel details cannot be considered without the review of an order or requisition form.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: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 serviceHCPCS 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 controlfor 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 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 medically reasonable or necessary. Our physician reviewer found the records do not sufficiently support the coding of both 80307 and G0483 due to lack of a supportive diagnosis for the listed drugs being tested and no indication for definitive testing. There is an order form, but it does not have complete information provided to justify the code.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 (CPT 80307 and HCPCS G0483) provided to the enrollee on January 10, 2020.
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-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with recent type III odontoid fracture, congestive heart failure, and chronic obstructive pulmonary disease and was admitted to the hospital after a fall at home. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He used oxygen via nasal cannula. He had rib fractures and an occult hip fracture, treated non-operatively. He was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand by assist to contact guard assist level with functional mobility including gait to 180 feet x 2. The enrollee required varying assist with activities of daily living. He became non-weight bearing with total dependent assist for transfers. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on December 17, 2019.You asked the Plan to pay for the nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 nursing facility care provided on December 17, 2019.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted
6/29/2020 with worsening leg pains. The enrollee suffered a fall in the bathroom, injuring the ankle and leg.
She was transferred to a SNF and has ongoing mobility deficits. She is non-toxic and hemodynamically stable.
Co-morbid conditions include congestive heart failure and anxiety. Functionally, she is mostly
minimal/moderate assist.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lesser level of care. Ongoing pain medication and other medication management, wound/skin
care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly
moderate/minimal assist for functional transfers and activities of daily living and a less intensive, longer
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An
IRF intensity is not warranted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing for an injection, chemotherapy administration, and rituximab. We decided that the Plan does not have to waive the cost-sharing for an injection, chemotherapy administration, and rituximab. You asked the Plan to waive the cost-sharing for an injection, chemotherapy administration, and rituximab. You say that you do not believe this charge is correct.The Plan says that this processed correctly. We decided that the Plan has to reduce the cost-sharing foran injection, chemotherapy administration, and rituximab. We also decided that the Plan does not have to waive the cost-sharing for an injection, chemotherapy administration, and rituximab.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 15% coinsurance for each Medicare-covered chemotherapy drug and administration of that drug, as well as Medicare-covered surgery or other services at an outpatient hospital or an ambulatory surgical center. The record shows that you have been asked to pay the full allowed amount for the services at issue. Based on the Plan contract, however, you cannot be asked to pay more than a 15% coinsurance for these services. Therefore, we decided that the Plan has to reduce the cost-sharing for an injection, chemotherapy administration, and rituximab to a 15% coinsurance.If the Plan does not agree with our decision,they canask 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 pre-approve SI joint radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that the enrollee's pain has affected her walking, and she has been unable to sleep. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure, because of the wide variation in efficacy and technique in the peer reviewed literature. Therefore, the procedure is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SI joint radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from February 8, 2020 through February 15, 2020.You asked the Plan to pay forinpatient mental health 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 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 appear to require inpatient mental health treatment as the enrollee was not a danger to themselves or others and were cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician was unable to find an individualized treatment found however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to themselves or others, auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any acute threat 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 forinpatient mental health care provided to the enrollee from February 8, 2020 through February 15, 2020.