Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 21, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 physician's services provided on November 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facility sleep study (polysomnography).
You asked the Plan to pre-approve polysomnography testing. You say that you have a history of sleep apnea and critical health conditions and are confined to a power wheelchair. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the documentation does not show that this testing is medically necessary for you.
The Plan follows Medicare rules. The rules say that polysomnography tests are only covered under certain clinical conditions when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve polysomnography testing. Our reviewer says that you do not meet the Medicare criteria for the requested polysomnography. Our physician reviewer found you have a history of obstructive sleep apnea and are on bi-level positive airway pressure (BiPAP). It appears that you need a replacement device. The records do not indicate that you were having problems with your current BiPAP settings, or that you had major changes in status or body weight that would change the PAP requirements. You have recently undergone attended diagnostic polysomnography confirming your diagnosis of severe obstructive sleep apnea. A repeat polysomnography test with PAP titration is not medically necessary; it would be reasonable to replace the BiPAP device to be used at the same settings as previously.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a facility sleep study (polysomnography).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 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 medical services provided to the enrollee by an out-of-network provider on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0249) provided on February 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services exceed the coverage limit.
The Plan must follow Medicare rules. Medicare rules say that code G0249 is allowed once every 25 days. We looked at the file and Medicare rules. The records show that code G0249 was paid by the Plan for date of service February 6, 2020. The services in question were provided less than 25 days after the paid services. 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 (G0249) provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on February 11, 2020, and March 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on February 11, 2020, and March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of axitinib and pembrolizumab.
You asked the Plan to pre-approve axitinib and pembrolizumab. You say that based on the guidelines and the available clinical information, you are requesting use of this drug combination. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because use of axitinib and pembrolizumab is not a supported mixture of drugs for subsequent therapy. The Plan also says that axitinib would be approved for the enrollee's condition.
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 axitinib and pembrolizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested drugs. Our physician reviewer found while the use of axitinib and pembrolizumab is, in general, approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis, it is not approved after failure of OPDIVO. Axitinib may be suggested as a single agent. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of axitinib and pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of axitinib and pembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for dermatology services provided on August 30, 2018.
You asked the Plan to waive the deductible for dermatology services. You say that you would like this deductible re-looked at. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for physician/practitioner services. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for physician/practitioner services. The total deductible amount that you are being asked to pay is $120.72. This cost sharing is a contractual obligation that had not been met at the time dermatology services was received on August 30, 2018. Therefore, we decided that the Plan does not have to waive the deductible for dermatology services provided on August 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on January 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric evaluation services (CPT 90792) provided to the enrollee on January 24, 2020.
You asked the Plan to pay for the services. You say that the rendering physician is a hospitalist physician with the group and depends on the hospital staff to verify eligibility and to obtain authorization. The Plan denied your request. The Plan says the enrollee has no out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychiatric evaluation services (CPT 90792) provided to the enrollee on January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve ongoing inpatient behavioral health services.
You asked the Plan to pre-approve the ongoing inpatient behavioral health services. You say that the Plan's set discharge date is too soon. The Plan denied your request. The Plan says that care beyond the approved date is not medically necessary.
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. Specifically, the Plan has not supplied us with any medical records. The Plan has not shown evidence of having attempted to obtain this necessary documentation. In addition, the treating facility is an in-network provider and is considered an agent of the plan. Medicare records should have been submitted, and without them we are unable to make a determination regarding the Plan's denial reason. Therefore, we decided that the Plan has to pre-approve ongoing inpatient behavioral health services.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 9, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) and transthoracic echocardiography (TTE) testing to be provided at the tertiary level of care.
You asked the Plan to pre-approve MPI and TTE testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee does not need to be treated at the tertiary level of care and can receive these tests from a non-tertiary level provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 MPI and TTE testing. Our reviewer says that the enrollee does not meet the Medicare criteria for receiving these services at the tertiary level of care. Our physician reviewer found the enrollee is recently stable with no documented urgent or emergent condition that would require tertiary level of care services as described.
The requested tests are common and can be provided safely and effective by a board-certified community-level provider. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested tertiary level of care provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MPI and TTE testing have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) and transthoracic echocardiography (TTE) testing to be provided at the tertiary level of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) endodontic therapy, root canal tooth 31 (D3330) intraoral-periapical first x-ray (D0220) provided on January 24, 2020.
You asked the Plan to pay for the dental services. You say that your dentist referred you to this provider for a root canal and you contacted the plan to confirm the procedure would be covered. You do not understand why the claim has not been paid. The Plan denied your request. The Plan says services from Medicare Opt-out providers are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for limited oral exam (D0140) endodontic therapy, root canal tooth 31 (D3330) intraoral-periapical first x-ray (D0220) provided on January 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computerized tomography (LDCT).
You asked the Plan to pre-approve the LDCT. You say that the records provided support the need for the requested LDCT. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that LDCT services are covered for certain indications. We looked at the file and Medicare rules. the records show that the enrollee is 78 years of age. Medicare rules state that a LDCT is only covered for enrollees between the ages of 55 and 77. Based on this information, we decided that Medicare rules for coverage of the LDCT have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose computerized tomography (LDCT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the IRF request 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 rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. Our reviewer also found that the documentation does not support that the enrollee's functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic Profiling testing provided on March 9, 2020 billed with multiple line items of different CPT codes.
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan says on review, it was found that no payment can be made for this testing because the provider is unbundling when there is a single CPT code which describes this testing.
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one unit of code 81479 should be reported with the appropriate DEX Z-code. As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic Profiling testing provided on March 9, 2020 billed with multiple line items of different CPT codes.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional home health visits.
You asked the Plan to pre-approve 60 additional home health visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the additional visits.
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 60 additional home health visits. Our reviewer says that 60 additional home health visits are not medically necessary at this time. Our physician reviewer found the documentation does not reveal that skilled therapy services are required to treat the patient's illness or injury, improve the patient's condition, maintain the patient's function or condition, or prevent deterioration of the patient's condition. The documentation does not reveal a certificate of medical necessity from the patient's physician or continued therapy. The documentation does not reveal that there is a new and significant decline in function or that the patient's functional level requires skilled therapy services. Furthermore, without the need for skilled therapy or skilled nursing services the request for home health aide services are not reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 60 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 60 additional home health visits.