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

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 18, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 code G0483 is 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. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for three (3) additional physical therapy visits provided from December 23, 2020, through December 31, 2020.
You asked the Plan to provide coverage for the three (3) additional physical therapy visits. You say that thought the original authorization was for the first 10 visits and he assumed that he was covered until he returned to his referring orthopedic physician on March 23, 2021. The Plan denied your request. The Plan says the physical therapy visits are 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 provide coverage for the three (3) additional physical therapy 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 therapy visits requested are not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. The medical 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 for physical therapy, by or under the supervision of a therapist. The documentation of the therapy notes does not support the need for skilled therapy on the dates in this appeal.
The documentation is also not clear on how many total visits of therapy you have had since your TKA or why you are unable to transition to an independent home exercise program. You should follow up with your physician with your range of motion concerns. 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 the three (3) additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide coverage for three (3) additional physical therapy visits provided from December 23, 2020, through December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on April 23, 2021 with bilateral leg swelling, redness, and edema. She was treated with intravenous antibiotics for cellulitis and improved. At time of hospital discharge she was not ambulatory and was maximum assist for transfers. She refused some treatment with physical therapy due to pain; physical therapy recommended restorative therapy for her follow-up treatment. She was discharged home on May 12, 2021. She has no skilled nursing needs. She has skilled therapy needs, but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not meet the criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the degree and duration of pain relief following diagnostic medial branch blocks. 

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 a lumbar facet joint radiofrequency ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 14, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you had this done at your dental provider's recommendation and did not realize it would not be covered. The Plan denied your request. The Plan says you also had an intraoral periapical x-ray (D0220) and an additional periapical image (D0230) on the date in question. Only two bitewing or intraoral periapical x-ray procedures can be covered in a calendar year. The Plan has paid for the intraoral x-rays provided on January 14, 2021; however, the bitewing x-rays exceed what is allowed by this benefit for this x-ray type.
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. The Plan can cover up to two x-rays per calendar year from the following list: intraoral periapical x-ray (first image), intraoral periapical x-ray (each additional image), bitewing (single film), bitewing (two films), bitewing (three films) or bitewing (four films). Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 14, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a thorax CT and an abdomen/pelvis CT provided on November 17, 2020.
You asked the Plan to pre-approve a computed tomography (CT), thorax; without contrast material (71250) and computed tomography, abdomen and pelvis; without contrast material (74176).. You say that the enrollee needs the CTs. The Plan denied your request. The Plan says that the records do not support the followup imaging time frame.
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 computed tomography (CT), thorax; without contrast material (71250) and computed tomography, abdomen and pelvis; without contrast material (74176). Our reviewer says that the CTs are medically necessary. Our physician reviewer found the rules say that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. In this case, the enrollee was diagnosed with metastatic lung disease in 2016 and underwent treatment. The enrollee had progression in 2020 and received additional treatment that was completed in July 2020. The enrollee had stable imaging in February 2021. The enrollee is less than one year following treatment. The requested services are medically reasonable and necessary as defined by Medicare rules. The elements of the coverage determination are satisfied. The requested service is recommended. 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 computed tomography (CT), thorax; without contrast material (71250) and computed tomography, abdomen and pelvis; without contrast material (74176). have been met. Therefore, we decided that the Plan has to pre-approve a thorax CT and an abdomen/pelvis CT provided on November 17, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthesis with an advanced foot and knee.
You asked the Plan to pre-approve a replacement prosthesis with an advanced foot and knee. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the records do not support that the enrollee has a K3 functional level necessary for the advanced foot and knee prosthesis.
The Plan follows Medicare rules. Medicare rules say that the advanced foot and knee prosthesis requires a K3 functional level for coverage to be approved. 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 replacement prosthesis with an advanced foot and knee. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 50-year-old male with a past medical history of hypertension, diabetes and a left above-the-knee amputation. Based on the medical records provided there is no documentation that the enrollee's functional level is currently K3. Provided records from the prescribing physician document: "GAIT presents in wheelchair." There are no other detailed records from the prescribing provider with regard to the enrollee's gait document current K3 status required for the requested prosthesis. 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 replacement prosthesis with an advanced foot and knee have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthesis with an advanced foot and knee.
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 will receive the appropriate level of care in the IRF setting. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ultrasound provided by a participating provider on August 10, 2020, to October 5, 2020.
You asked the Plan to waive the coinsurance for an ultrasound. You say that you thought that prior authorization would cover this fully. 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 $160 copayment for outpatient diagnostic tests/in-network/radiological diagnostic services. You have been asked to pay less than a $160 copayment for an ultrasound. The total amount you are being asked to pay is $1,209.72 which is less than your copayment amount total of $1,440 ($160 x 9 ultrasounds = $1,440). An ultrasound falls within the outpatient diagnostic tests/in-network/radiological diagnostic 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 coinsurance for an ultrasound provided by a participating provider on August 10, 2020, to October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on October 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided by a participating provider on February 14, 2020, to February 19, 2020.
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you were an inpatient. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient hospital services/observation. You have been asked to pay a 20% coinsurance of the allowed amount for outpatient hospital services. The total allowed amount is $11,104.55. The total amount you are being asked to pay is $2,220.91 ($11,104.55 x 20% = $2,220.91). Outpatient hospital services fall within the outpatient hospital services/observation 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 coinsurance for outpatient hospital services provided by a participating provider on February 14, 2020, to February 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine 5 mg tablet.

You asked the Plan to pre-approve Prochlorperazine. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. This drug is not being administered to a patient for nausea related to chemotherapy. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine 5 mg tablet.

Benefits for Prochlorperazine 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Infliximab.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a history of Crohn's disease of moderate to severe severity and has failed conventional therapies. She is on the requested medication and the prescriber has requested a dose escalation. The Medicare compendia do not restrict the dose. The Infliximab is safe and effective and reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Infliximab.
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 pre-approve 17 additional rest home visits.
You asked the Plan to pre-approve these services. You say that you can't use your walker and it is too hard to travel to your primary care physician. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that rest home visits are covered when specific criteria are met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you are in an alternate living facility. The records do not support any rationale for the 17 requested visits. There is no documentation to support that the additional visits are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 17 additional rest home visits.
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 an IRF admission. The Plan denied your request. The Plan says the enrollee is non-weight bearing to the right lower extremity which would make a comprehensive therapy program inappropriate.
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 health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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.