Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
March 21, 2019 to May 10, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the location
where skilled nursing or therapy visit services were provided must always be reported along with the first visit
reported on the claim. In addition to reporting a visit line using the G codes, Home health agencies must report
an additional line item with the same revenue code and date of service, reporting one of the three Q codes
(Q5001, Q5002, and Q5009), one unit and a nominal covered charge. On the corrected claim submitted, the
revenue of the additional line is not the same as the revenue reported on the first visit line. Therefore, we
decided that the Plan does not have to pay for the home health services provided to the enrollee from March 21,
2019 to May 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for outpatient services rendered outside of the United
States.
You asked the Plan to reimburse you for the outpatient services. You say that you would like reconsideration
because this provider was recommended to treat your condition. The Plan denied your request. The Plan says
Medicare will not pay for non-emergent services provided outside of the United States of America.
The Plan must follow Medicare rules. Medicare rules say that except for specific services, items and services
furnished outside the United States are excluded from coverage.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient services have not been met. Medicare does not pay for non-emergent services
provided outside of the United States. Additionally, this provider is not eligible to participate in Medicare.
Therefore, we decided that the Plan does not have to reimburse you for outpatient services rendered outside of
the United States.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemcitabine Hydrochloride and Paclitaxel.
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says guidelines
do not recommend the use in the adjuvant treatment of pancreatic cancer.
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 the requested drugs. Our physician
reviewer found that the enrollee has cancer of the ampulla of vater. The requested drug combination is not
FDA-approved for the enrollee's diagnosis. It is only approved as a monotherapy or in other combinations, but
not with the proposed use. The requested use is not supported by one of the major drug compendia or by
clinical research that appears in a CMS-approved medical journal. Therefore, the requested drugs 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 the requested drugs have not been met. Therefore, we decided that the Plan does
not have to pre-approve Gemcitabine Hydrochloride and Paclitaxel.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.
You asked the Plan to pre-approve TTE test. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee had a similar study performed and additional imaging is not supported without a clear reason why it is needed.
The Plan follows Medicare rules. Medicare rules say that TTE tests are covered when used for medically appropriate applications.
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 TTE test. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested TTE test. Our physician reviewer found based on the records the enrollee has known heart disease and congestive heart failure symptoms with 2 recent echocardiograms on January 14, 2020 and July 7, 2020. There is no documentation to support the medical necessity for an additional echocardiogram. Coverage criteria are not met because there is no documented covered indication for this test. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTE test have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for transfer
are not met.
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 is an 82 year old female who was admitted with acute respiratory failure
with hypoxia, COVID-19 viral pneumonia, and COPD exacerbation. She was treated with antiviral medication,
IV fluids, antibiotics, steroids, and nebulizer treatments. She required BiPAP but since has transitioned to high
flow oxygen and is tolerating occupational therapy most recently. The enrollee does not require services at the
LTACH that are not already available at the current acute care hospital. The enrollee appears to be improving
enough to expect the current acute care hospital stay to be less than 25 days. There are no services available at
the LTACH that the enrollee requires that are not already being received or available and covered at the current
facility. There is no advantage to transfer the patient at this time. Therefore, this request for LTACH services
will be considered 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's needs could be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the records do not show that the enrollee has
any identifiable skilled therapy needs. While the enrollee has skilled nursing needs, he does not need skilled
nursing services on a daily basis. He 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional supplies for a continuous glucose monitor.
You asked the Plan to pre-approve additional supplies. The Plan denied your request. The Plan says a supplier must not dispense more than a three-month quantity of testing supplies at a time.
The Plan must follow Medicare rules. Medicare rules say that regardless of utilization, a supplier must not dispense more than a three-month quantity of BGM testing supplies at a time. The documentation shows that 12 months of continuous glucose monitor supplies were requested. The Plan has agreed to pre-approve 3 months of supplies. We looked at the file and Medicare rules. Medicare does not cover more than 3 months of supplies at a time. 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 pre-approve additional supplies for a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH 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 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 does not require services at the LTACH that are not already available at
the current acute care hospital. The enrollee appears to be improving enough to expect the current acute care
hospital stay to be less than 25 days. There are no services available at the LTACH that the enrollee requires
that are not already being received or available and covered at the current facility. There is no advantage to
transfer the patient at this time. Therefore, this request for LTACH services will be considered 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the enrollee does not check his blood glucose four or more times a day.
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under certain medical 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 the requested item. Our physician reviewer found that the enrollee has type II diabetes with neuropathy, and an A1c level of 7.8%. She is on Lantus insulin once daily and Janumet twice daily. There is no documentation that the enrollee is insulin-treated with three or more daily injections of insulin, or is using a Medicare-covered continuous subcutaneous insulin infusion pump, or that she has been using a blood glucose monitor to perform testing four or more times a day. Therefore, the requested device is not considered medically reasonable and 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 requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee had normal exercise capacity, and no EKG changes that would prevent interpretation of a routine stress test.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the imaging. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has significantly increased coronary risk, known vascular disease (prior stroke), a normal electrocardiogram and chest pressure that is anginal in quality by report. Current guidelines endorsed by several national organizations consider nuclear stress testing appropriate in this setting of moderate-to-high pretest risk, anginal symptoms and a normal electrocardiogram. Coverage criteria above for nuclear stress testing are met since one covered indication includes "Assessment of the functional and prognostic importance of angina".
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 imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the neck.
You asked the Plan to pre-approve an MRI of the neck. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says an MRI is not a service that a member can obtain without a physician's order or approved referral.
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 the request for an MRI of the neck is not supported in the case file. A physician has not submitted an order or referral for an MRI of the neck. Therefore, we decided that the Plan does not have to pre-approve an MRI of the neck.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve push handles and bag hooks for a wheelchair.
You asked the Plan to pre-approve the wheelchair accessories. The Plan denied your request. The Plan says
these items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. This items are
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve push handles and bag hooks for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture (D5214).
You asked the Plan to pre-approve the dental service. You say that you received your partial about 4 years ago
and they never told you that you could come back to the office and get it adjusted. Because of pain, you tried to
fix it and it broke. The Plan denied your request. The Plan says this request exceeds the benefit frequency
limitations.
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. This service is covered once
every 5 years. The records show that this service was provided April 9, 2018.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
lower partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular pathology testing provided on November 13, 2019.
You asked the Plan to pay for the Guardant360 molecular pathology testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, and 81321 are not supported in the medical record. Specifically, the services rendered should be identified with code 81479. In addition to this code, the appropriate DEX Z-code identifier should be put adjacent to the CPT code 81479 in the comment/narrative field of the claim. Based on this information, we decided that Medicare rules for coverage of the Guardant360 molecular pathology testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 molecular pathology testing provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Praluent pen.
You asked the Plan to pre-approve a Praluent pen. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says a Praluent pen is not covered under the enrollee's Medicare
Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Praluent pen.
Benefits for a Praluent pen may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to waive the cost sharing for the Velcade injections. We decided that the Plan does not have to waive the cost sharing for the laboratory services and echocardiogram.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan says that the cost sharing was applied correctly.
We decided that the Plan has to waive the cost sharing for the Velcade injections.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for in-network Medicare Part B covered drugs.
Review of the file shows that you received Velcade injections on January 3, 2020; January 10, 2020; and January 17, 2020. The Plan says you must pay a 25% coinsurance for these services; however, based on the Plan contract, you cannot be asked to pay more than a 20% coinsurance for these services. Therefore, we decided that the Plan has to waive the cost sharing for the Velcade injections rendered from January 3, 2020 to January 17, 2020.
We also decided that the Plan does not have to waive the cost sharing for the echocardiogram and lab services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $100 copayment for in-network basic radiological services at an outpatient hospital and a $45 copayment for in-network lab services at an outpatient hospital.
Review of the file shows that you received an echocardiogram on February 12, 2020. You have been asked to pay a $100 copayment for these services. These services fall within the in-network basic radiological services at an outpatient hospital 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.
The file shows that you received lab services on February 21, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the in-network lab services at an outpatient hospital 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 sharing for the echocardiogram and lab services rendered on February 12, 2020 and February 21, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core build-up (D2950) of tooth #18.
You asked the Plan to pre-approve the core build-up. You say that the requested core build-up is medically necessary. The Plan denied your request. The Plan says this service is not a covered procedure.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core build-up (D2950) of tooth #18.