Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy (PT) and occupational therapy (OT).
You asked the Plan to pre-approve PT and OT. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because there are no progress notes from previous therapy visits to determine whether therapy is still needed.
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 pre-approve PT and OT. 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 the documentation does not support that the requested therapy is generally accepted as a specific and effective therapy for the enrollee's condition. The enrollee has had extensive prior therapy and it is unclear whether she has had significant objective measurable improvement from this therapy. The records do not support that she requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge, and judgment of a qualified therapist is not required to establish, design, and/or deliver a program to maintain the enrollee's 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 PT and OT have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy (PT) and occupational therapy (OT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the submitted documentation does not contain enough detail to support the billed charges.
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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found there was no evidence provided of a relationship between the patient and ordering physician. HCPCS G0481 is for definitive testing, however, there was no provided evidence of prior abnormal preliminary drug testing results to justify using this code, however, the order form appears to match this code as there was multiple drug classes to be tested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora duplex scan provided on February 17, 2020.You asked the Plan to waive the copayment fora duplex scan. You say that you disagree with the charges and feel that they are too high.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $110 copayment for radiological diagnostic services. You have been asked to pay a $110copayment for a duplex scan. A duplex scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 fora duplex scan provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the plan did not receive records showing that an ARU or SNF evaluation
has been completed.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and a crown (D2740).
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not covered by Medicare or the enrollee's 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. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and a crown (D2740).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve8 fractions of brachytherapy. We decided that the Plan does not have to pre-approve9fractions of brachytherapy. You asked the Plan to pre-approve8 fractions of brachytherapy. You say that HDR Brachytherapy allows a more custom, direct radiation dose delivery.The Plan says that brachytherapy is not considered a standard of care approach for treatment of skin cancer. We decided that the Planhas to pre-approve8 fractions of brachytherapy. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, thenthat 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 8 fractions of brachytherapy. Our physician reviewer found that radionuclide brachytherapy is a historical treatment modality for skin cancers, and a variety of effective treatment techniques and dose schedules have been developed and used for both LDR and HDR treatments. This form of brachytherapy is particularly useful for patients that may benefit from a shorter treatment course or more precise dosimetry that this modality allows as compared to external beam techniques and should be considered a standard radiotherapy option. Notably, this enrolleeis not being offered a short course of treatment,and there is no indication that a more precise dosimetryis needed. While NCCN guidelines do not advocate for the use of brachytherapy for skin cancers, it is clear that several American societies consider it an accepted standard of care. Thus, standard medical necessity criteria are met for the treatment.Standard treatment options, based on the American Brachytherapy Society consensus statement, would be 6-8 fractions(as HDR allows for escalation of the fractional dose). Therefore, up to 8 fractionsare considered medically reasonable and necessary.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on October 4, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of HCPCS code G0482 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; 15-21 drug class(es), including metabolite(s) if performed." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence of provider concern for drug abuse/misuse. The two custom profiles, which are dated months prior to the DOS, do not include patient identifying information. A specific order/requisition related to the DOS has not been submitted for review.
Therefore, the documentation does not support that the provided UDS and UDT were medically necessary, reasonable or properly ordered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3320) for tooth #5.
You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says the root canal benefit has a limit to 1 per calendar year. The Plan says that the enrollee's history plus this request have gone over the limit.
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, root canals are limited to 1 per calendar year. The record shows that the enrollee received endodontic treatment on tooth #7 on April 30, 2020 and the enrollee's endodontic therapy (root canal) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy (D3320) for tooth #5.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSupartz FX injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy guidelines were not followed.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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physicianreviewer found the documentation does not support that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Supartz FX injection is not approved as step criteria is 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveSupartz FX injection for the enrollee.
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 the enrollee still needs close monitoring
of his acute needs. The Plan denied your request. The Plan says the enrollee's needs are being met in the current
setting.
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 physician
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee
requires that are not available at the health care setting being offered by the health plan. The requested LTACH
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee
and able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by a nonparticipating
provider.
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 services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 7, 2020
by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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. Therefore, we decided that the Plan does not have to pre-approve Lyrica.
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on February 27, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you should be reimbursed in full because these services are covered under your plan.The Plan denied your request. The Plan says since the treating provider is OON, the Plan pays according to a maximum allowable fee schedule and you are responsible for all fees in excess of this amount from the billed amount. The Plan also says that your cost share was calculated correctly.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, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decidedthat the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on February 27, 2020 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3320) provided on February 12, 2020.
You asked the Plan to pay for endodontic therapy (D3320). You say that the tooth needed repairing to prevent the infection from spreading. You say that payment should be made due to underlying medical issues. The Plan denied your request. The Plan says the service 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 endodontic therapy (D3320) provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482)
provided to the enrollee on June 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the plan was unable to discover any evidence of an established relationship between the member
and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service.
HCPCS G0482:
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; 15-21 drug class(es), including
metabolite(s) if performed
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found no
provider records have been submitted for review. Therefore, there is no evidence of provider concern for drug
abuse/misuse. The custom toxicology profile, dated one month prior to the DOS, contains no patient
identifying information. A signed and dated order relevant to the DOS has not been submitted for review. The
lab results have not been submitted for review. Therefore, the documentation does not support that the provided
UDS and UDT were medically necessary, reasonable, properly ordered or performed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on June 24,
2019.