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

We decided that the Plan does not have to pre-approve the 9 additional home health care skilled nursing visits.You asked the Plan to pre-approve additional home health care skilled nursing visits. You say that you do not have opposition to use your fingers on your right hand. You also say that you are unable to do your own wound dressing.The Plan denied your request. The Plan says the medical records show that your condition is improving, and this will allow the home health team to continue to care for your needs and start transition of care.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 additional home health care skilled nursing visits. Our reviewer says that the remaining 9 skilled nursing visits are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you. Our reviewer found that your wound care needs are not complex. Our physician reviewer also found that you have had extensive skilled nursing care and education on your condition and you do not need the skills of a professional nurse for ongoing 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 additional home health care skilled nursing visits have not been met.Therefore, we decided that the Plan does not have to pre-approve the 9 additional home health care skilled nursing visits.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided to the enrollee on December 20, 2019.
You asked the Plan to pay for the services. You say that bill type 321 means the patient was admitted and
discharged within the same episode. The Plan denied your request. The Plan says that this was billed an
incorrect type of bill.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We asked our coding 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 reviewers says that the
services at issue in this case were coded correctly. Our coding reviewer found the bill type is 321 - Home
health services admit thru discharge. All services provided by home health per physician orders carried out,
until decision to admit to hospice care.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for
home health services provided to the enrollee on December 20, 2019.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 22 additional home health nursing visits.
You asked the Plan to pre-approve additional home health nursing visits. 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 home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional home health nursing visits.
Our reviewer says that the documentation does not support that the requested services are medically reasonable
or necessary. Our physician reviewer found you have wound care needs. The documentation does not support
that skilled nursing services are required to effectively provide treatment, care, and/or services in order to
improve your condition, or to establish/perform a maintenance program to maintain your condition and/or
prevent deterioration. Your needs are not at a skilled nursing level and your wound care is not so complex that
you require ongoing skilled nursing services for 22 more visits for your medical 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 additional home health nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 22 additional home health nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on February 18, 2020.
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that the testing at issue was not billed as outlined in the Medicare rules. 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 testing provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on November 27, 2019.
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says the Plan covers care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on November 27, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Cxbladder testing provided on January 29, 2020.
You asked the Plan to pay for the testing services. You say that the Cxbladder test was ordered to aid in the diagnosis of new or recurrent bladder cancer. The Plan denied your request. The Plan says that tests with no relation to a medical diagnosis of disease for the health of the enrollee is not a benefit.
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 pay for the testing services. Our physician reviewer found that the medical records show the enrollee had gross hematuria. A cystoscopy was reported negative. The Cxbladder test detected 100% T1-T3 Tis tumors and detected 97% all high-grade tumors. Therefore, the provided testing was medically reasonable and necessary to treat the enrollee. 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 testing services have been met. Therefore, we decided that the Plan has to pay for the Cxbladder testing provided on January 29, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that there are no required medical services identified that are
available at the LTACH, that are not available at the current healthcare 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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient
is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. The enrollee is not
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term
care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for
LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kyprolis (carfilzomib) treatments.
You asked the Plan to pre-approve the Kyprolis treatments. You say that it is felt this treatment is medically necessary. The Plan denied your request. The Plan says this drug is approved for use in combination with Darzalex for relapsed or refractory multiple myeloma. This is requested for use for maintenance therapy for MM in remission. This is not supported by literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Kyprolis treatments. Our reviewer says that the requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of multiple myeloma (MM) with multiple lines of prior treatment since diagnosis in 2012. The current request is daratumumab with Kyprolis for maintenance. This is not an FDA-approved regimen for maintenance of MM. There is no support found the major drug compendia or CMS-approved medical journals for this treatment. As such, the request is 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 Kyprolis treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Kyprolis (carfilzomib) treatments.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on November 14, 2019.
You asked the Plan to pay for the molecular pathology services. The Plan denied your request. The Plan says prior authorization was not obtained.
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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for molecular pathology services provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 14, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were advised by an insurance agent the provider was listed as an in-network provider. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Review of the file show that you received the dental services on January 14, 2020 provided by an out-of-network provider. Your EOC states, to be covered in-network, you need to use a provider that is contracted with our dental vendor to provide supplemental dental services. Care rendered by a provider that is not part of our supplemental dental network is not covered." 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 dental services provided on January 14, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicarerules. 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 wascorrect 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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing supervision in an IRF. While you may benefit from additional physician and occupational therapies, the documentation does not indicate that you require this therapy on an intensive rehabilitation therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 20, 2019.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. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says assistance with basic activities of daily living may be provided by non-skilled personnel.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 physician reviewer found that the enrollee is hemodynamically stable presently, and neurological exams are stable. 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 is at minimal to standby assist for functional transfers and activities of daily living. The enrollee does not require treatment by multipletherapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the morphometric analysis services coded 88360, the surgical pathology services coded 88305, and the immunohistochemistry services coded 88342 and 88341 provided on October 24, 2019.You asked the Plan to pay for the morphometric analysis services, the surgical pathology services coded 88305, and the immunohistochemistry services. 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 claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 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, we have confirmed that code 88342has a bundled relationship with code 88360and cannot be paid as billed. This code cannot be paid as a separate line item. In addition, since code 88342 is being denied, the add on-code, CPT 88341 cannot be paid as well. Based on the claim submitted, Medicare billing criteria have not been met.In this case, the MUE for CPT code 88360 is 6. You billed 26 units of this code, exceeding the MUE. The MUE for CPT code 88305 is 16. You billed 26 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the morphometric analysis services, the surgical pathology services coded 88305, and the immunohistochemistry services have not been met.Therefore, we decided that the Plan does not have to pay for the morphometric analysis services coded 88360, the surgical pathology services coded 88305, and the immunohistochemistry services coded 88342 and 88341 provided on October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec ODT.
You asked the Plan to pre-approve Nurtec ODT. The Plan denied your request. The Plan says this drug is not
covered for your condition by your Plan's Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nurtec ODT.
Benefits for Nurtec ODT 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: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Euflexxa is 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 Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on July 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON domiciliary or rest home visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 domiciliary or rest home visit provided on July 19, 2019 by an out of network (OON) provider.