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

We decided that the Plan does not have to pay for the hereditary cancer panel provided to enrollee on February 12, 2019.You asked the Plan to pay for the testing services. You say that due to a family history, the enrollee would benefit from a screening.The Plan denied your request. The Plan says there are no signs, symptoms, or indications in the medical records the treating physician requested cancer testing.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested for screening purposes. There were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cancer panel provided to enrollee on February 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 12, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 12, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on March 28, 2019.You asked the Plan to pay for the x-rays. You say that the services are not hospice related. You say that these should be processed.The Plan denied your request. The Plan says Original Medicare is responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the x-rays provided on March 28, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 10, 2019 to May 31, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration as this claim was billed correctly. The Plan denied your request. The Plan says payment is not allowed for this claim because the FIPS code is missing or invalid.
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 claim that was submitted does not include the required FIPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 10, 2019 to May 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation provided on August 23, 2019 to August 30, 2019.You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you called and made sure that this was in-network and covered.The Plan denied your request. The Plan says these services are covered. The Plan says that the correct copayment has been applied to the service that was provided.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 $50 copayment for cardiac rehabilitation services/in-network. You have been asked to pay a $50 copayment for cardiac rehabilitation. Cardiac rehabilitation falls within the cardiac rehabilitation services/in-network 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 cardiac rehabilitation provided on August 23, 2019 to August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve providedon October 9, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 27, 2018.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 the testing is not covered.The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified. 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 laboratory services rendered on December 27, 2018.
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 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. 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 enrollee does not require skilled nursing or therapy services on a daily basis. The 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Fx (J7321).
You asked the Plan to pre-approve Supartz Fx. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Supartz Fx. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz Fx have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Fx (J7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX injections for the enrollee.You asked the Plan to pre-approveSupartz FX. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided thatthe Plan does not have to pre-approveSupartz FX injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of topical fluoride varnish provided on August 8, 2019.
You asked the Plan to pay for the application of topical fluoride varnish. You say that you were informed this was included in your Plan. You say that you were not informed this type of fluoride treatment would not be approved. The Plan denied your request. The Plan says this is not a covered benefit.
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 pay for the application of topical fluoride varnish provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and dry pressure mattress.
You asked the Plan to pre-approve a semi-electric hospital bed (E0260) and dry pressure mattress (E0184) from an out-of-network provider. You say that the recommended suppliers are either closed or cannot supply the requested hospital bed. The Plan denied your request. The Plan says they have in-network providers for the bed and mattress.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan has confirmed with the providers listed that they are open and can provide the semi-electric hospital bed and dry pressure mattress. We found no exception that would require the Plan to pre-approve these items from an out-of-network supplier. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and dry pressure mattress from the out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were going to dinner at your daughter's house when your blood sugar levels got too low. You were unresponsive so your family called for an ambulance which came and helped bring your sugar levels back up. After you recovered you thought you were okay so you declined going to the hospital. You say that the services should be covered since you were treated by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 21, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home enteral nutrition therapy provided from October 8, 2019 to October 28, 2019.
You asked the Plan to pay for the services provided. You say that the records support the billed services. The Plan denied your request. The Plan says the code is not valid for Medicare purposes.
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 S9343 is home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem. We find that CPT code S9343 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the home enteral nutrition therapy provided from October 8, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ranibizumab injection services.
You asked the Plan to pre-approve the Ranibizumab injection services. You say that Avastin has never been approved by the FDA for intraocular injection. You say that Avastin is not prepared under the same manufacturing conditions that are used to manufacture either Lucentis or Eylea, but is prepared by compounding pharmacies. You say that compounding pharmacies are not subject to the same regulatory scrutiny as FDA approved drugs. You say that there have been instances of contaminants within medications from compounding pharmacies, which have caused serious and permanent injury to patients. Bevacizumab has been used for many years as an off-label treatment for neovascular ARMD. Based on numerous clinical trials, these medications have both been found to be effective in the treatment of this condition and have similar adverse event profiles. Therefore, it is unlikely that the required drug, Bevacizumab, would be less effective or have adverse effects for the enrollee. The Plan denied your request. The Plan says the clinical information does not show that the requested drug is medically necessary. The Plan says that there is no documented failure or contraindication to the health plan's preferred products. The Plan says that the enrollee's preferred product for the enrollee's diagnosis is Avastin.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Ranibizumab injection services. Our reviewer says that the criteria for coverage of the requested drug have not been met. Our physician reviewer found the enrollee has a new diagnosis of wet ARMD in the left eye. The enrollee has not yet received treatment for this condition and has neither tried nor failed the required drug Bevacizumab/Avastin. 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 Ranibizumab injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Ranibizumab injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee cannot walk or stand. You have a roll in shower and a physical therapist recommended that you get a larger shower chair with arms. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.You asked the Plan to pre-approve additional visits. You say that the enrollee is receiving therapy for weakness, poor balance, gait issues, and risk of falling.The Plan denied your request. The Plan says 8 additional visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.The file shows that 10 physical therapy visits were requested for the enrollee. The plan has agreed to pre-approve 2 visits. 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 8 additional visits. Our physician reviewer found that the enrollee has a diagnosis of unsteadiness on feet, receiving therapy for weakness, poor balance, gait issues, and risk of falling. He resumed therapy for the above complaints on January 2, 20202, with good improvements in strength, balance and posture significantly; and improved his tolerance to stairs and walking with better endurance. Based on review of the available records, the enrollee does not meet criteria for continuation of therapies beyond the approved 2 visits. Treatment appears to be repetitive and working for the same areas with only goal is to achieve higher level of function, which was not clearly stated in the notes. Therefore, the remaining 8 visits are not 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Aflibercept (eylea) injection (J0178).
You asked the Plan to pre-approve Aflibercept (eylea) injection. You say that at no time is it acceptable to have a patient lose vision in order to gain better control of their wet macular degeneration. The vision that is lost may not ever be regained. The Plan denied your request. The Plan says that 8 injections of Avastin was partially approved.
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 Aflibercept (eylea) injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based on documentation, it is medically reasonable for the patient to have Eylea injections. The enrollee has known wet ARMD with active CNV in the left eye since 5/2019. She has received multiple injections of Avastin and a single injection of Eylea. It is documented that the enrollee has a good response to Eylea sample. The safety and efficacy of the medication has been studied in numerous clinical trials. Based on documentation, patient's diagnosis supports treatment with antivegF agent, such as Eylea, which has been FDA approved for this condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aflibercept (eylea) injection have been met. Therefore, we decided that the Plan has to pre-approve Aflibercept (eylea) injection (J0178).