Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator and portable oxygen system provided on December 8, 2019. You asked the Plan to pay for the oxygen concentrator and portable oxygen system rental. You say that you need this equipment to survive.The Plan denied your request. The Plan says documentation supporting medical necessity for the equipment was requested from the supplier but not received.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  We looked at the file and Medicare rules. There is no physician order or documentation supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator and portable oxygen system rental have not been met.Therefore, we decided that the Plan does not have to pay for the oxygen concentrator and portable oxygen system provided on December 8, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received on December 30, 2018.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are not payable.The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. The records show that the services in question were provided by a provider of the same specialty and same group practice as services previously paid by the plan. This means that the services in question are not payable under Medicare rules. However, it should be noted that the group practice should bill for the services of both physicians under one code, and you should not be billed for the second physician's services separately. If this happens, you should contact the plan. 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 forthe services you received onDecember 30, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on July 16, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered on July 16,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on February 13, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you were not told blood work performed at the doctor's office would be billed differently than blood work performed in an outpatient facility. 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 laboratory services at an in-network outpatient hospital. You have been asked to pay a $50 copayment for the laboratory services. The laboratory services fall 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 laboratory services provided on February 13, 2020.
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 based on the provided medical records the enrollee is receiving the necessary services
in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to
transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute
rehabilitation facility.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on January 13, 2020.
You asked the Plan to pay for the drug testing. You say that drug testing is a useful component of chemical dependency treatment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. We looked at the file and Medicare rules. There is no evidence that shows the test was individualized to identify specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Medicare does not cover these services 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 presumptive and definitive drug testing provided on January 13, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the short-latency somatosensory testing rendered on January 27, 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 that procedure code 95938 was not submitted with an appropriate diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that procedure code 95938 was not billed with an appropriate diagnosis; however, the Plan has not provided any Medicare rules or documentation to support that the claim is not payable as billed. The Local Coverage Article (LCA) referenced by the Plan is not valid for the services at issue, as it is for the incorrect jurisdiction. Therefore, we decided that the Plan has to pay for the short-latency somatosensory testing rendered on January 27, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan.The Plan denied your request. The Plan says weight loss is not a valid indications for a CT scan of the abdomen and pelvis. The Plan says that a CT scan is not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only 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 the CT scan. Our reviewer says that the requested CT scans are not medically reasonable and necessary. Our physician reviewer found the enrollee is reported to have unintended weight loss. There are no complaints of localized pain or abnormal physical examination findings. Basic laboratory studies were non-actionable. It does not appear that a CXR was ordered or performed. There is no evidence of a plan to send the enrollee fora GI evaluation or endoscopies.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of the torus mandibularis.
You asked the Plan to pre-approve the requested dental service. You say that without the procedure, your dentures will not fit properly. The Plan denied your request. The Plan says the removal of torus mandibularis is not a covered service.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of the torus mandibularis.
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 you are appealing for IRF admission so the enrollee can regain function, ambulate safely, perform ADL's and return home to assisted living and to his community with improved quality of life. The Plan denied your request. The Plan says IRF admission is not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 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 current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) and Gelsyn-3 (J7328) provided on
October 30, 2019.
You asked the Plan to pay for the office visit and Gelsyn-3. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the services billed.
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 99214 is office or other outpatient visit for the evaluation
and management of an established patient, which requires at least 2 of these 3 key components: A detailed
history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient
and/or family.
The CPT Code Manual definition of CPT code J7328 is hyaluronan or derivative, gelsyn-3, for intra-articular
injection, 0.1 mg.
We asked our coder 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 office visit and Gelsyn-3. Our reviewer says that CPT
code 99214 does not meet criteria for billing or reimbursement consideration. CPT code 99214 is included in
the global day period of the arthrocentesis service (20160). Our reviewer found CPT code J7328 does not meet
criteria for billing or reimbursement consideration. The medical records provided do not include documentation
to corroborate 336 units of Hyaluronan or derivative, GELSYN-3, for intra-articular injection, 0.1 mg being
administered on October 30, 2019, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit and Gelsyn-3 have not been met. Therefore, we decided that the
Plan does not have to pay for an office visit (99214) and Glesyn-3 (J7328) provided on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of an 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that 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 needs can be met at a lower level of
care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network
(OON) provider at the in network level.
You asked the Plan to pre-approve these OON services to be provided at the in network level. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services can be provided by a network provider.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services to be provided at the in network rates. While you may receive
services from this provider, the cost share amounts will be higher. Therefore, we decided that the Plan does not
have to pre-approve medical services to be provided by an out of network (OON) provider at the in network
level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane.
You asked the Plan to pre-approve the Abraxane. You say that the records provided support the need or the
drug in dispute. The Plan denied your request. The Plan says cancer related medical journals and drug reference
books do not support this drug to treat the enrollee's specific cancer.
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 the Abraxane. Our reviewer says that
the criteria for coverage of the requested drug has not been met. Our physician reviewer found Abraxane is
only approved by the FDA for the enrollee's diagnosis in the 1st line of therapy. The use of Abraxane is not
supported by any of the major drug compendias or by clinical research that appears in a CMS-approved
medical journal.
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 Abraxane have not been met. Therefore, we decided that the Plan does not
have to pre-approve Abraxane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism of the seat lift chair purchased on
January 28, 2020.
You asked the Plan to pay for the seat lift mechanism. You say that you were not told by the Plan an
authorization was required. The Plan denied your request. The Plan says you did not have a prescription and
the records do not show the chair is part of your course of treatment.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We looked at the file and Medicare rules. There is no standing written order from your physician. Based on this
information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met.
Therefore, we decided that the Plan does not have to pay for the seat lift mechanism of the seat lift chair
purchased on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with power Tilt-In-Space and
accessories.
You asked the Plan to pre-approve a manual wheelchair with power Tilt-In-Space and accessories. You say that
the enrollee needs the power tilt feature and accessories. The Plan denied your request. The Plan says the
enrollee is able to propel a wheelchair and lives in a long term care facility with 24 hour care.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF to be a home.
Records show that a manual wheelchair with power Tilt-In-Space and accessories is being requested for use in
a SNF. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with power Tilt-
In-Space and accessories.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 31, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were performed in good faith. The
Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and
authorization for certain 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 OON services. Therefore, we decided
that the Plan does not have to pay for the medical services provided on October 31, 2019 by an out of network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the orthotics to make it easier to walk
or stand without unbearable pain. The Plan denied your request. The Plan says this item is not a covered
benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.