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

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on January 29, 2020.You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told the procedure would be fully covered and your only cost would be the specialist 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 $325 copayment for each Medicare-covered in-network ambulatory surgical center visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the diagnostic colonoscopy. You have been asked to pay a $246.99 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows that polyps were removed during your colonoscopy which makes the colonoscopy diagnostic in nature.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus Anser ADA testing provided on November 1, 2019.You asked the Plan to pay for the Prometheus Anser ADA testing. You say that the Prometheus Anser ADA testing was medically necessary.The Plan denied your request. The Plan says the Prometheus Anser ADA testing was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Prometheus Anser ADA testing. Our reviewer says that the Prometheus Anser ADA testing was not medically necessary. Our physician reviewer found the Prometheus Anser IFX test series is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies, and the Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. These are proprietary studies performed only by Prometheus Labs. The tests are not FDA approved. Some evidence exists that low serum levels of infliximab or adalimumab and/or the presence of antibodies to infliximab or adalimumab may play a role in primary or secondary response failures.Available records include a test requisition, with no patient name and no clinical diagnosis. Results of the Prometheus Anser ADA panel, collected on 11/1/2019 and reported on 11/12/2019, were provided. The documents provided do not support the medical necessity of the above assay under review. The American Gastroenterological Association (AGA) issued in August, 2017 new guideline recommendations on therapeutic drug monitoring (TDM) in patients with inflammatory bowel disease (IBD) treated with anti-TNF agents and thiopurines. Pertinent to this review, AGA conditionally suggested use of reactive TDM to guide treatment changes in patients with active IBD, but acknowledged there currently exist no defined cut-offs by which to judge low versus high titer anti-drug antibodies. AGA avoided sanctioning routine proactive TDM of anti-TNF therapy in patients with quiescent IBD.While available records do not support that the enrollee lost response to Humira at the time of his Anser study (and thus did not meet the spirit of the AGA recommendations above, nor medical necessity criteria for the testing), it is recognized that the contemporary medical literature is replete with both proponents and detractors of the presently-disputed Prometheus Anser assay under review.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 Prometheus Anser ADA testing have not been met.Therefore, we decided that the Plan does not have to pay for the Prometheus Anser ADA testing provided on November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 1, 2020.You asked the Plan to waive the copayment for the ambulance transport. You say that this was a matter of life and limb. You say that you were advised by the doctor to take an ambulance.The Plan denied your request. The Plan says the copayment applied 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 $325 for Medicare-covered ambulance services per trip.You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the emergency room. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 1, 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 enrollee meets the Medicare criteria for IRF.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 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 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. The enrollee's medical status does not currently require intensive rehabilitation physician and nursing oversight only in an IRF. While the enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation does not support that the enrollee can tolerate an 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you provided this lab tests in good faith. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 lab work provided on February 11, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOpdivo and Yervoy.You asked the Plan to pre-approveOpdivo and Yervoy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 Opdivo and Yervoy. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has stage IV pheochromocytoma/adrenocortical cancer. The requested use of Opdivo and Yervoy are not FDA-approved for the enrollee's diagnosis. The requested use of Opdivo and Yervoy is not supportedby one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The enrollee has MSI high and high TMB  so the combination of opdivo/yervoy is not supported for this tumor type or this indication. Therefore, the enrollee does not meet criteria for the requested drugs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo and Yervoy have not been met.Therefore, we decided that the Plan does not have to pre-approveOpdivo and Yervoy.
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 can't breathe well. 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on June 9, 2020 with leg swelling and shortness of breath. You had stable vital signs and were treated for congestive heart failure. You received physical and occupational therapy in the hospital and need assistance with mobility and activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided on February 6, 2020.
You asked the Plan to pay for the dental services. You say that had you known this would have been an issue, along with the current dental office inability to obtain information as to the use of previously related benefits, you would have taken another approach. The Plan denied your request. The Plan says this service exceeds the frequency limitation.
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 health plan contract says that this service is covered once every 3 calendar years. The records show that this service was provided September 18, 2018. Therefore this benefit is exhausted. 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 pay for comprehensive oral exam (D0150) provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of right knee
pain and is status post right knee radiofrequency ablation. Genicular nerve blocks and genicular nerve ablation
are considered investigational and are not medically necessary for the treatment of chronic knee pain. The
services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laminectomy.
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 services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. The criteria for surgery are not met, as there is no documentation of a recent trial and failure of physical therapy. There are no noted red flags for surgery. The procedure is therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a laminectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for detailed and extensive oral evaluation - problem focused, by report (D0160), diagnostic casts (D0470), occlusion analysis - mounted case (D9950) and unspecified diagnostic procedure, by report (D0999) provided on February 26, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for detailed and extensive oral evaluation - problem focused, by report (D0160), diagnostic casts (D0470), occlusion analysis - mounted case (D9950) and unspecified diagnostic procedure, by report (D0999) provided on February 26, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH 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 medical records show acute care appears to be still required at least for a short while until stable for discharge. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. Medicare coverage criteria for transfer are not met. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee only uses insulin twice a day, and does not require frequent insulin adjustment.The Plan follows Medicare rules. Medicare rules say that 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 device. Our physician reviewer found that the enrollee has a history of diabetes mellitus. She is treated with insulin twice a day. She checks her blood glucose levels twice per day. Medicare rules say that the enrollee should be insulin-treated with multiple (three or more) daily injections. based on the records, the enrollee does not meet the coverage criteria for the requested device.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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of care at a LTACH.
You asked the Plan to pre-approve the continuation of care at a LTACH. You say that the requested
continuation of care at a LTACH is medically necessary. The Plan denied your request. The Plan says the
requested continuation of care at a LTACH is not medically necessary.
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 continuation of care at a LTACH.
Our reviewer says that the requested continuation of care at a LTACH is not medically necessary. Our
physician reviewer found the enrollee was admitted with respiratory insufficiency, pneumonia, interstitial lung
disease, pelvic rami fracture and chronic obstructive pulmonary disease and later transferred to a LTACH on
6/16/20. Upon review of the most recent records showed that the enrollee's vitals were stable and normal and
significant overall clinical improvement was noted. She was recently feeling well and breathing well with
supplemental oxygen and requires ongoing therapy and steroids which could be continued at a lower level of
care at this point. Therefore, based on the provided documentation, this request for continuation of 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 continuation of care at a LTACH have not been met. Therefore, we decided
that the Plan does not have to pre-approve the continuation of care at a LTACH.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 4, 2020.You asked the Plan to waive the copayment for the office visit. You say that you went for your annual wellness visit. You say that you weren't told that discussing other health concerns would change the visit to a standard office visit.The Plan denied your request. The Plan says the copayment applied 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 $10 copayment for PCP office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for hyperlipidemia, incontinence and dermatitis during the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on March 4, 2020.