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

We decided that the Plan does not have to pay for the drug testing coded G0483 You asked the Plan to pay for the drug testing.You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymaticmethods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering physician to show the specific drugs being tested for. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 19, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because the documentation submitted does not include a valid physician order, lab requisition, or medical
records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Foam Roller (A9270).You asked the Plan to pre-approve the foam roller. You say that this item would help you relax your muscles since you have arthritis and swollen feet.The Plan denied your request. The Plan says this item is not a covered benefit.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 Foam Roller (A9270).
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 transfer to an LTACH is 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 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 based on the documentation provided, the enrollee is currently undergoing treatment
at an acute care hospital (ACH) for shortness of breath. The enrollee was transiently intubated/ventilated but
was extubated and is no longer on a ventilator. There is no evidence that the enrollee requires services that are
not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. Medicare coverage criteria for transfer are 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to preapprove
long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forKeytruda (J9271).You asked the Plan to pay forKeytruda. You say that this will improve the enrollee's quality of life.The Plan denied your request. The Plan says this drug has not been established as first line therapy.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 payfor Keytruda. Our reviewer says that Keytruda is not medically necessary and supported in this case. Our physician reviewer found Keytruda is not FDA approved for first line therapy of gastroesophageal cancer nor is it supported by major drug compendia orthe medical literature. This patient's tumor is HER2 positive and HER2 based therapy is recommended for first line treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pay forKeytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory test. You say that the enrollee did not have the option to have this testing performed by an in-network provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 November 13, 2019 by an out of network (OON) provider.
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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not 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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bilateral subdural hemorrhages. The enrollee is not intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. Medicare criteria for transfer are 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 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 drug testing provided on December 2, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the level of physician and nursing involvement of the enrollee's medical management is not available at a less intensive level of care.The Plan denied your request. The Plan says the enrollee does not have active medical issues that require being seen by a rehab physician 3 times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's current level of function is moderate assist for bed mobility, total assist for transfers, moderate assist for grooming, and minimal to maximum assist for upper and lower body dressing. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, thefile, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you have to prick your finger two times a day and it is causing pain and numbness on your fingertips. The Plan denied your request. The Plan says you do not meet criteria for a continuous glucose monitor. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you do not test four or more times a day and you are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 20, 2020 to January 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. 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 physician services provided on January 20, 2020 to January 24, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leucovorin.
You asked the Plan to pre-approve Leucovorin. The Plan denied your request. The Plan says this drug it 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 Leucovorin. Our reviewer says that Leucovorin is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that per NCCN guidelines, without high risk features for resected stage II disease, there is no role for adjuvant 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 Leucovorin have not been met. Therefore, we decided that the Plan does not have to pre-approve Leucovorin.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic nuclear medicine provided on February 13, 2020.
You asked the Plan to waive the copayment for diagnostic nuclear medicine. You say that you were told that you would only owe a $25 copayment and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for each radiological diagnostic service. You have been asked to pay a $150 copayment for diagnostic nuclear medicine. Diagnostic nuclear medicine 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 diagnostic nuclear medicine provided on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea fourth dental extraction of tooth #28.You asked the Plan to pre-approvethe additional dental extraction. You say that you will need to go off of your blood thinners in order to have the three teeth removed and it is dangerous for you do a second procedure and cannot afford to pay for this out of pocket at this time.The Plan denied yourrequest. The Plan says your dental benefit only covers up to three extractions per calendar year. Since three extractions have been approved, no further procedures can be covered for this year.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, this is limited to only three extractions per calendar year.Therefore, we decided that the Plan does not have to pre-approvea fourth dental extraction of tooth #28.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Hyalgan. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of osteoarthritis of the knees. The documentation does not support that the enrollee has a trial and failure of the required drugs of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective or likely have adverse effects on the enrollee. Therefore, the enrollee does not meet criteria for the requested drug, Hyalgan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tamsulosin HCL capsule.
You asked the Plan to pre-approve Tamsulosin HCL capsule (J8499). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
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 Tamsulosin HCL capsule.
Benefits for Tamsulosin HCL capsule (J8499) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a naturopathic herbal treatment patch.
You asked the Plan to pre-approve herbal treatment patch. You say that you need this for pain control. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this herbal patch is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The rules also say that drugs that are usually self-administered are not covered by Medicare Part B. The herbal patch at issue in this appeal is a naturopathic treatment. Additionally, this patch would not be covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a naturopathic herbal treatment patch.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. 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 proton beam therapy . Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee stage IIB prostate cancer. The enrollee has a Gleason score of 7. The enrollee has a prostate specific antigen score of 16. Per NCCN, radiation consortium proton beam therapy is not indicated. Therefore, the enrollee does not meet criteria for the requested 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stairway elevator for the enrollee.
You asked the Plan to pre-approve the elevator. You say that this is medically necessary. The Plan denied your request. The Plan says this is excluded from Medicare coverage.
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 stairway elevator for the enrollee.