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

We decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on July 31, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says the documentation submitted indicates that the specimen was collected in an office setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code, but the records indicate that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 you do not require the intensity of care provided at an IRF. You are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you are weak and need rehab. The Plan denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on April 26, 2021 with acute respiratory failure. You received oral and inhaled medications and had stable vital signs. You received physical and occupational therapy in the hospital and need assistance with walking 200 feet with a rolling walker. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided from October 16, 2020, to October 21, 2020.
You asked the Plan to pay for critical care. You say that this should be covered. The Plan denied your request. The Plan says this 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical care services is not documented in the records. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided from October 16, 2020, to October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this request is
medically necessary. The Plan denied your request. The Plan says coverage criteria for the therapeutic
continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of the
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the patient is a 79-year-old male who was admitted to the current acute care hospital
with COVID pneumonia and acute respiratory failure requiring mechanical ventilation. The patient appears to
be unstable and requires additional short term acute care services for additional weaning which can safely be
completed at the current facility. There are no services at the LTACH that the patient requires that are not
already available and covered at the current facility. Transfer to a lower level of care may be considered when
treatment has completed and when more stable.
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on November 4, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that the member did not call 911. The Plan denied your request. The Plan says the correct copayment has been applied.

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 contract with the Plan clearly says that enrollees must pay a $220 copayment for ambulance services.

The enrollee has been asked to pay a $220 copayment for ambulance services. The correct copayment has been applied to the services that were provided. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 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 for ambulance services provided by a participating provider on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit securement package (K0108).
You asked the Plan to pre-approve a transit securement package. You say that this is a needed item. The Plan denied your request. The Plan says this does not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a transit securement package (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).

You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have 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 Ilumya. Our reviewer says that the criteria for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial of Remicade or Inflectra; and Stelara before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the the plan's required drugs would likely be less effective or have adverse effects for 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 Ilumya have not been met.

Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Bevacizumab, Carboplatin, Paclitaxel and Palonosetron.

You asked the Plan to pre-approve Bevacizumab, Carboplatin, Paclitaxel and Palonosetron. You say that the requested Bevacizumab, Carboplatin, Paclitaxel and Palonosetron are medically necessary. The Plan denied your request. The Plan says that the requested Bevacizumab, Carboplatin, Paclitaxel and Palonosetron are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Bevacizumab, Carboplatin, Paclitaxel and Palonosetron. Our reviewer says that the requested Bevacizumab, Carboplatin, Paclitaxel and Palonosetron are medically necessary. Our physician reviewer found the enrollee is with recurrent ovarian cancer with liver metastasis. The enrollee is with platinum sensitive relapse of ovary cancer. The enrollee has relapsed while on maintenance Avastin. The provider has supplied a study published in lancet oncology showing efficacy of continuing Avastin passed progression. The requested Bevacizumab, Carboplatin, Paclitaxel and Palonosetron are 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 Bevacizumab, Carboplatin, Paclitaxel and Palonosetron have been met. Therefore, we decided that the Plan has to pre-approve Bevacizumab, Carboplatin, Paclitaxel and Palonosetron.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on November 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided to you by an out-of-network provider on November 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) home health skilled nursing visits, six (6) home health physical therapy visits, and six (6) home health occupational therapy visits, for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 the services. Our physician reviewer found the documentation does not support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Furthermore, there is no indication that the enrollee is homebound. The requested home health services are 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) home health skilled nursing visits, six (6) home health physical therapy visits, and six (6) home health occupational therapy visits, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl.
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 self-administered drugs are not covered.
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 Fentanyl.
Benefits for these services 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that the requested care is a necessity for the enrollee. The Plan denied your request. The Plan says the requested care is not medically necessary because step therapy rules have 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 Euflexxa. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of unilateral primary osteoarthritis of the left knee. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The case file does not contain documentation of trial and failure of Orthovisc and Monovisc. 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided September 28, 2020.
You asked the Plan to pay for the orthosis. You say that you trust that the verification provided will be deemed sufficient to allow you to verify the claims at issue to remit payment for the pending claims as soon as possible The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim.
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 find that CPT codes L1833 and L2397 are not supported in the medical record. Specifically, the provider is not listed in the enrollee's history of claims. There are no claims on file with the ordering physician listed in the claims history from 2019 - present. The enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section. 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 enrollee is a 64 year old female who was admitted to the acute care hospital on April 12, 2021. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and approaching their baseline. Additional short-term acute care services are required to complete treatment which can safely be received at the current acute care facility. The enrollee does not require LTACH services that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered soon when treatment has completed. 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 LTACH services.