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

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on April 4, 2019.You asked the Plan to pay for the drug testing. You say that this was medically necessary and ordered by the treating physician.The Plan denied your request. The Plan says there is no signed order for this testing and no record showing the intent for this testing.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider. In this case, there is no clear order form which clearly indicates the testing being requested. The only document which appears to have an order has an undefined panel being requested and is not signed. There are also no records to support the intent to provide this testing.Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on April 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) rendered on
February 28, 2020.
You asked the Plan to waive the copayment for these services. You say that you were not previously charged
for this test. The Plan denied your request. The Plan says the copayment was 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 $20
copayment for Medicare-covered non-radiological diagnostic services.
Review of the file shows that you received an EKG on February 28, 2020. Per your contract with the plan,
there is a $20 copayment for Medicare-covered non-radiological diagnostic services. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed
amount for these services was $16.35. Given that the allowed amount was less than the $20 copayment, you
have been asked to pay $16.35 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG)
rendered on February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forstereotactic radiosurgery (61798) provided on January 8, 2020.You asked the Plan to pay forstereotactic radiosurgery. You say that this code is supported.The Plan denied your request. The Plan says this code is not documented in the records.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 61798 is  stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion.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 stereotactic radiosurgery. Our reviewer says that the billing of this code is not supported. Our physician reviewer found the operative report did not include lesion measurements to support that there was a complex cranial lesion, therefore, this code cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stereotactic radiosurgery have not been met.Therefore, we decided that the Plan does not have to pay forstereotactic radiosurgery (61798) provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing forthe DME provided from February 10, 2019 through November 9, 2019 from an out-of-network provider.You asked the Plan to waive the cost-sharing forthe DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the DME February 10, 2019 throughNovember 9, 2019 from an out-of-network provider. At the time of services rendered you had not met your $500 deductible; therefore, you have been asked to pay $490.26? for the services to apply to your deductible. You then met your deductible and were asked to pay 25% coinsurance for out-of-network DME. Your EOC states, your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you mustpay the full cost of your covered services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. Enrollees must pay 25% coinsurance for out-of-network DME." 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 cost-sharing forthe DME provided from February 10, 2019 through November 9, 2019 from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Brovana 15 mcg/ 2ml Nebulizer Solution (J7605).You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to the medication Perforomist (formoterol).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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of this medication. Our physician reviewer found that this appeal considers the request for Brovana 15mcg/2mlnebulizer solution for the treatment of chronic obstructive pulmonary disease. Step therapy, as outlined by the plan, requires a trial of drug Perforomist (formoterol). Reviewed medical documentation does not support a trial of Perforomist. Without the support of the documentation, Brovanais 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 this medication have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Brovana 15 mcg/ 2ml Nebulizer Solution (J7605).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of ophthalmology services provided to the enrollee on November 7, 2019.You asked the Plan to pay for the additional units. You say that this should be paid for.The Plan denied your request. The Plan says the submitted medical records do not support the units billed.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 66984 is "Extracapsular cataract removal with insertion of intraocular lens prosthesis."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 additional units. Our reviewer says that the medical records do not support the additional units billed. Our physician reviewer found the enrollee underwent cataract extraction and lens implantation with laser on 11/7/19. CPT code 66984-55, RT (8 Units) was billed. The units are used to indicate the exact number of post-operative days the provider cares for the patient. Allowance of the postoperative care for each practitioner will be according to the number of days each practitioner was responsible for the patient's postoperative care. The enrollee's right eye was evaluated on 11/8/19. On 11/14/19, the enrollee underwent cataract surgery on the left eye. The enrollee was seen in follow-up on 11/15/19. The documentation does not support the billing of CPT code 66984-55, RT (8 Units).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 additional units have not been met.Therefore, we decided that the Plan does not have to pay for additional units of ophthalmology services provided to the enrollee on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel for 8-14 drug classes provided on July 15, 2019.
You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary testing and the order was included to show the intent for this testing. The Plan denied your request. The Plan says the order form provided is not valid and does not support billing of G0481.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. In this case, the order form included in the file is missing page 2 of 2. Based on review of the one page included, only four separately reportable drug classes are noted. As such, the order form does not support the intent to bill for 8-14 drug classes. Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel for 8-14 drug classes provided on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-One (J7326). You asked the Plan to pre-approve the Gel-One. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.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 Gel-One. Our reviewer says that Gel-One does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee has not trialed visco supplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed first. Our reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer also found that without the support of the documentation, Gel-One 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 Gel-One have not been met.Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged ($1301.29) for inpatient care provided to the enrollee from October 9, 2017 to October 18, 2017.You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct.The Plan denied your request. The Plan says this copayment was charged by the provider based on the services provided and the 2017 Plan contract agreement.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's 2017 contract with the Plan clearly says that enrollees must pay $300 per day for days 1 to 5 of an inpatient stay. This would be a total of $1500. In this instance the enrollee is being charged less than the normal copayment expectation. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment charged ($1301.29) for inpatient care provided to the enrollee from October 9, 2017 to October 18, 2017.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the CT Scan of the soft tissue of the neck. You say that you would like reconsideration because you tried to get authorization before the member came but never received a fax. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan 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. 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 March 31, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 22, 2019 through November 29, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 22, 2019 through November 29, 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 pay for the home infusion therapy (HIT) administrative services
provided from December 11, 2019 to March 5, 2020 billed with code S9328.
You asked the Plan to pay for the HIT services. You say that this claim is for payment of services related to
infusion via a pain management pump and the enrollee was referred by a network provider. The Plan denied
your request. The Plan says home infusion therapy and/or implanted pump pain management infusion services
are not allowed when billed by a non-participating provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code S9328 has a status indicator of "I" in the Physician Fee Schedule, meaning it is invalid for Medicare
billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services
have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy
(HIT) administrative services provided from December 11, 2019 to March 5, 2020 billed with code S9328.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the full body (78816).
You asked the Plan to pre-approve a PET CT scan of the full body. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET CT scan of the full body. Our reviewer says that the services are medically necessary. Our physician reviewer found in this case, the enrollee meets all criteria for this exam coupled with the fact that post op they had a negative Axumin scan previously. Thus, a baseline PET/CT is available for comparison. As the attending urologist points out the therapy will be totally different based upon the presence or absence of metastatic disease. If the scan shows likely local recurrence the enrollee can be treated with targeted radiotherapy whereas distant metastases will require androgen deprivation as well as other chemotherapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan of the full body have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the full body (78816).
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 acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status or activity tolerance requires 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: 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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in 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-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 the Guardant360 testing provided on November 20, 2019.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has stage III/B/IV colorectal cancer. Guardant360 has been performed two previous times for this cancer diagnosis. The requested Guardant360 testing is 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 the testing have not been met.Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on November 20, 2019.