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

We decided that the Plan does not have to pay for outpatient lab work provided on December 18, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 outpatient lab work provided on December 18, 
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the removal of excess skin.
You asked the Plan to pre-approve the requested services. You say that your problems are a direct result of major weight loss. The Plan denied your request. The Plan says that you are not suffering from chronic medical complications related to the pannus.
The Plan follows Medicare rules. Medicare rules say that excision, excessive skin and subcutaneous tissue may also be considered to be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication. 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 requested services. Our physician reviewer found that you underwent sleeve gastrectomy in June of 2017, resulting in more than a 100-pound weight loss. The area underneath your pannus is pruritic and frequently has a foul odor. You have had excoriation, which has been treated by your primary care physician with prescribed emollient. Photographs show evidence of a moderately overhanging lower abdominal pannus obscuring the pubic region. You have excessive skin and subcutaneous tissue of the lower abdomen following the significant weight loss. You have evidence of medical complications, including chronic intertrigo and excoriation (tissue necrosis) that has been unresponsive to topical medication. Therefore, a lower abdominal panniculectomy should be considered 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve the removal of excess skin.
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 this level of care is appropriate for the member. The Plan denied your request. The Plan says that the LTACH offers no additional services.
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 review indicates that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 23, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for NSCLC, and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code [81479] in the comment/narrative field.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 23, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network.
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 lab services provided to the enrollee on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 24, 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 October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vascular diagnostic study provided on February 6, 2020.
You asked the Plan to waive the copayment for the vascular diagnostic study. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic procedures and tests. You have been asked to pay a $50 copayment for the vascular diagnostic study. The vascular diagnostic study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the vascular diagnostic study provided on February 6, 2020.
Your complaint that this was a bad experience and caused you unnecessary worry is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
provided on January 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
rendered are not a covered benefit. 
 
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 psychiatric diagnostic evaluation with medical 
services provided on January 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 23, 2020.
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 January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (0232T, 99070) provided on March 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the requested services are not covered.
The Plan must follow Medicare rules. Medicare rules say that A57743 provides a list of non-covered CPT codes. We looked at the file and Medicare rules. Per A57743, CPT code 0232T is a non-covered code. As the primary procedure is non-covered, the requested supplies are also non-covered. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (0232T, 99070) provided on March 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 21, 2020 to February 24, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 21, 2020 to February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 31, 2019 to
January 6, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically
necessary. The Plan denied your request. The Plan says that that there is insufficient information provided to
determine if the member did or did not improve within an observation timeframe.
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. The review
indicates 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 and/or observation
care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare
criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from December 31, 2019 to January 6, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 28 additional weeks of treatment of Procrit.
You asked the Plan to pre-approve additional weeks of treatment of Procrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested additional treatment of this drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 additional weeks of treatment of Procrit. Our reviewer says that the documentation does not support that the requested additional treatment of Procrit is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of stage IV chronic kidney disease and anemia. Regular (weekly) monitoring of hemoglobin levels is recommended upon initiation of Procrit therapy and discontinuation for lack of hemoglobin responsiveness after 12 weeks of escalating dosage is also recommended, as further dosage increase is unlikely to improve response. Therefore, the enrollee does not meet criteria for the requested 52 weeks of Procrit treatment. Review of the file shows that the plan uses Local Coverage Determination, LCD L34356 to support their denial. However, LCD L34356 is not valid for the enrollee's home state of Michigan. Therefore, we cannot use LCD L34356 to substantiate our decision. 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 weeks of treatment of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve 28 additional weeks of treatment of Procrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from February
4, 2020 to February 14, 2020.
You asked the Plan to pay for this service. You say that this service was provided in good faith and should be
paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for
out of network care and chiropractic services are only covered in network.
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 contract also specifically states that chiropractic care is only
covered in network.
Your office and staff are not in network. This type of service is only covered in network. The Plan did not preapprove
these services. 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 chiropractic services provided to the enrollee from February
4, 2020 to February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 13, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 domiciliary, rest home visit provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve the requested services. You say that you are in extreme pain that is causing depression. The Plan denied your request. The Plan says the medical records do not show that your depression and anxiety are under control.
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain medical indications. 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 requested services. Our physician reviewer found that you have chronic widespread pain. You have had 7 surgeries on your foot, and have diabetes with peripheral neuropathy. You had an MRI which shows foraminal stenosis. You have the diagnosis of Complex Regional Pain Syndrome, but the Budapest criteria are not addressed. You had an Epidural Steroid injection with 50% pain relief. However, there is no documentation of any sympathetic blocks or physical therapy for treatment. Psychological testing revealed that you have depression, but there is no ongoing therapy documented. Therefore, the requested service is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 13, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for NSCLC, and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code [81479] in the comment/narrative field.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 13, 2020.