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

We decided that the Plan does not have to pay for the WATS 3D brush testing provided on October 29, 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 in this case is a 68-year-old male with past medical history of gastro-esophageal reflux disease without esophagitis who underwent an EGD with WATS 3D biopsy to evaluate for possible Barrett's esophagus. The most current published evidence regarding safety and effectiveness of the WATS 3D brush biopsy procedure suggests an improvement on the standard random forceps-based biopsy in terms of safety and detection of Barrett's and adenocarcinoma. However, there were no found studies to date which described a statistically significant improvement in morbidity and mortality in patients directly related to adenocarcinoma from using the WATS 3D biopsy method. Therefore, it appears that this investigational biopsy method is still under study is considered not medically necessary 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 testing have not been met.Therefore, we decided that the Plan does not have to pay for the WATS 3D brush testing provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January 7, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that this was a routine eye exam. The Plan denied your request. The Plan says this was not a routine eye exam.
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 shows that you received a medical eye examination provided on January 7, 2020. You are asked to pay a $30 copayment for the medical eye exam. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the medical eye exam provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 pre-approve inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 27, 2020 forward. The enrollee was not shown to be a danger to herself as she has passive thoughts but not others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats to the safety of herself or others.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that a shower chair is medically necessary.The Plan denied your request. The Plan says shower chairs are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says the records do not support the need or daily therapy on an inpatient basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the skilled nursing facility. By the dates in question, the enrollee was at a maximal to total assist level with functional mobility. The enrollee requires varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
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 would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 rulesto 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 requiredmoderate assistance with bed rolling, standing up, sit down, and transfers. You required maximum assistance to sit up and lie down. The documentation does not support that you require the intensity of services provided at an IRF. Specifically, you are notshown to be able to perform fifteen hours per week of rehabilitative services with 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Panniculectomy (15830 and 15847).
You asked the Plan to pre-approve a Panniculectomy (15830 and 15847). You say that the requested Panniculectomy is medically necessary. The Plan denied your request. The Plan says the requested Panniculectomy 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 pre-approve a Panniculectomy (15830 and 15847). Our reviewer says that the requested Panniculectomy is not medically necessary. Our physician reviewer found the enrollee had requested a panniculectomy. Medical documentation from 3/20/20 noted that the enrollee had undergone a gastric bypass in 2016 resulting in significant weight loss. She has a history of intertrigo. Examination notes a relatively large abdominal pannus that is heavy. She does not have any infection. Plan is for panniculectomy and umbilicoplasty. The enrollee reports that she has a 2-year history of skin irritation and rashes. Photographs show evidence of a lower abdominal pannus with dermal irritation. The enrollee is with evidence of a large overhanging lower abdominal pannus that has been symptomatic with chronic rashes. However, typical dermatologic management of her chronic rashes has not been adequately documented. Based on Medicare medically necessary criteria, symptoms should be shown to be refractory to usual standard medical therapy. This has not been adequately documented and thus panniculectomy does not satisfy Medicare medically necessary criteria. 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 Panniculectomy (15830 and 15847) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Panniculectomy (15830 and 15847).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found based on the medical records provided, the enrollee no longer required SNF services after June 4, 2020. The enrollee was receiving oral medications.The enrollee had stable vital signs. He was alert with confusion.By the dates in question, the enrollee was at an independent to minimal assist level with functional mobility including gait to 125 feet with a rolling walker or cane. The enrollee requiredvarying assist with daily activities. Medicare criteria for SNF admission are no longer 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infliximab injection provided on June 17, 2019, July 23, 2019, August 28, 2019 and October 3, 2019.
You asked the Plan to waive the coinsurance for the infliximab injections. You say that you weren't charged for previous claims. You say that you are on a fixed income and are having a hard time understanding the changes. The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for chemotherapy drugs and other Part B drugs. You have been asked to pay a total of $2,020.16 for the infliximab injections.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
June 17, 2019
Infliximab Injection
$2,651.96
20%
$530.39
July 23, 2019
Infliximab Injection
$2,651.96
20%
$530.39
August 28, 2019
Infliximab Injection
$2,398.45
20%
$479.69
October 3, 2019
Infliximab Injection
$2,398.45
20%
$479.69
TOTAL:
$2,020.16
The infliximab injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the infliximab injection provided on June 17, 2019, July 23, 2019, August 28, 2019 and October 3, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on May 17, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the claim is a duplicate to an already paid claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The case file does not contain evidence that the laboratory services were billed and paid for by the Plan in order to determine if the denied claim was a duplicate. Therefore, we decided that the Plan has to pay for the laboratory services provided on May 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of SNF care. The Plan says that there are no noted daily skilled complex nursing or therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. The enrollee had a cholecystostomy drain and wound care to multiple decubitus ulcers. The enrollee received physical therapy, occupational therapy, and speech therapy in the SNF. By the dates in question the enrollee was dependent for functional mobility. The enrollee required varying assist with activities of daily living. She tolerated a pureed diet and nectar thickened liquids. There are identifiable skilled nursing service needs, but they are not required on a daily basis. There are no identifiable skilled therapy service needs. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code G0365 provided on June 24,2019.You asked the Plan to pay forCPT code G0365. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. The file shows the enrollee received services while in an outpatient setting. The claim was filed with a primary diagnosis code of Z01.818. Medicare says Z codes may be used as a first-listed principal diagnosis code in an inpatient setting. The enrollee received services in an outpatient setting.Therefore, we decided that the Plan does not have to pay forCPT code G0365 provided on June 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the enrollee requires custodial care. The Plan says that
the clinical information provided does not support the medical necessity of a SNF stay.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, and was alert with confusion. The enrollee had difficulty following
directions and one-step commands. The enrollee received physical therapy and occupational therapy in the
acute hospital. The enrollee was at maximum assist level with functional mobility. The enrollee required
varying assist with activities of daily living. There are no identifiable skilled therapy service needs. There are
no identifiable skilled nursing service needs.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the care neededin skilled nursing facility.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 reasonableand necessary in this case. There are no required services at the LTACH that are not available at the current acute care hospital. 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 enrollee's need can be safely and effectively treated at the current facility or a skilled nursing facility. Our physician reviewer found 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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you required contact guard assistance to stand-by assistance during all mobility training with intermittent shortness of breath and dizziness with activity. You have no complex wound care needs or IV medication requirements. Your vital signs were stable. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of intravenous immune globulin (IVIG Privigen).
You asked the Plan to pre-approve Privigen. You say that you are appealing. The Plan denied your request. The
Plan says the denial of authorization for this drug is correct, because there is not enough published evidence to
show that maintenance therapy or repeated treatment regimen is safe and helpful for the enrollee.
The Plan follows Medicare rules. Medicare rules say that intravenous immune globulin (IVIG) such as Privigen
is only covered under certain conditions 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 Privigen. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested Privigen. Our physician reviewer found the notes
provided for review show that this request is for maintenance infusions. This is not an indication for which
Medicare recommends the use of Privgen as it is not being used for an acute exacerbation. Therefore, the
requested Privigen is not medically reasonable and necessary 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 Privigen have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of intravenous immune globulin (IVIG Privigen).