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

We decided that the Plan does not have to waive the copayment for the laboratory work provided on March 3, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory services were a part of your annual physical exam and should have a $0 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 $20 copayment for in-network Medicare-covered non-preventive laboratory services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the laboratory services.
You have been asked to pay a $10.09 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received non-preventive laboratory work.
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 laboratory work provided on March 3, 2020.
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 February 6, 2020.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 February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 12, 2019.
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 says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided did not clearly support a clinical scenario suggesting the above tests were being used for any other reason besides screening, and there was no existing condition listed in the documentation which would change the treatment strategy for this patient based on the results of the above. Therefore, without sufficient support made, the above tests will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelumbar medial branch radiofrequency ablation (RFA) for the enrollee.You asked the Plan to pre-approvethe injection. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee only received one set of lumbar spine facet MBBs.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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had only one set of diagnostic medial branch blocks, rather than the dual diagnostic blocks that are required. Therefore, this request is considered not medically reasonable or necessary at this point.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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar medial branch radiofrequency ablation (RFA) for the enrollee
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay fordrug testing services (HCPCS G0483) provided to the enrollee on August 22, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says that the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code  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 enzymatic methods (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 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 services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found there is an itemized list of tests to be performed, and a signed statement from the provider acknowledging the CPT codes in question. This establishes a relationship. The documentation supports the code.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theservices have been met.Therefore, we decided that the Plan has to pay fordrug testing services (HCPCS G0483) provided to the enrollee on August 22, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We onlyopen a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided onMarch 26, 2020.You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 servicesat 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 radiology services provided on March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee has not completed the full course in the hospital.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) after being struck by a rolling car/trailer resulting in C4 quadriplegia. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator. It is unclear if full ventilator liberation is achievable. Decannulation seems unlikely. 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.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.
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 you need the requested shower chair because you could slip in the shower at any time. You say that you are trying to avoid injury and potential accidents that could result from a fall. You asked the Plan to reconsider providing coverage for the requested shower chair.The Plan denied your request. The Plan says this item is not a covered benefit.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated oral device for obstructive sleep apnea (E0486).You asked the Plan to pre-approve the oral device. You say that the enrollee is at risk of severe apnea without being treated. The enrollee is not sleeping at all and with excessive drowsiness can lead to accidents and even death.The Plan denied your request. The Plan says the criteria has not been met for the requested custom fabricated oral device. 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 the oral device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no evidence of face-to-face evaluation by the pulmonologist (specialist who manages and monitors the correct use of the PAP) indicating the non-tolerability of the PAP device, no evidence of adjustments of PAP parameters such as pressures, modalities and monitoring through smart card or report of applications of the PAP device by the pulmonologist. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.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 oral device have not been met.Therefore, we decided that the Plan does not have to pre-approve a custom fabricated oral device for obstructive sleep apnea (E0486).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with hypertension and chronic kidney disease stage II. The enrollee was admitted 7/17/2020 with shortness of breath and altered mental status, found to have acute encephalopathy and positive COVID-19.Hospital course included antibiotics and supportive care, and the enrollee has improved. She is now moderate/maximum assist for care and non-toxic. No fever or leukocytosis is seen. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on October 21, 2019.
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the validity and accuracy of the claim cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary.
In this case, the CPT Code Manual definition of code G0481 is drug testing for 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify specific non-prescribed medications or illicit substances. This testing is not covered for screening purposes. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided on October 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits and home health aide services.
You asked the Plan to pre-approve skilled nursing visits and home health aide services. 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. 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 skilled nursing visits and home health aide services. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found the enrollee has been receiving home health nursing services May 21, 2020 through July 19, 2020. The documentation does not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The documentation does not support that the home health aide services are reasonable and necessary to the treatment of the enrollee'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 skilled nursing visits and home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits and home health aide services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the skin tag removal provided on December 12, 2019.You asked the Plan to pay for the skin tag removal. You say that the skin tag removal was medically necessary.The Plan denied your request. The Plan says that the skin tag removal is considered cosmetic.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 skin tag removal. Our reviewer says that the skin tag removal was medically necessary. Our physician reviewer found the enrollee had a large, irritating skin tag removed on her posterior left thigh. It was approximately 2 cm and would get caught in clothing. The above guidelines allow for removal of symptomatic benign skin lesions as in this case. The above list is not an exhaustive list. Therefore, as this was a large symptomatic (irritating and getting caught in clothing) benign skin lesion, its removal satisfies the above guidelines and should have been 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 skin tag removal have been met.Therefore, we decided that the Plan has to pay for the skin tag removal provided on December 12, 2019.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.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 they are 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. The clinical assessment in the case file does not support
that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
the enrollee 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 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 a domiciliary, rest home visit provided on January 27, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 27, 2020.