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

We decided that the Plandoes not haveto pre-approvea one-month extension of Integrated Pain Management.You asked the Planto pre-approvethe extension. You say that this is medically necessary for your digestive problem, and you do not want to take medication.The Plandenied your request. The Plansaysthis program is only available for 12 months.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 extension. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there has been no documented improvement in pain. The physical exam findings have not changed over the course of the therapy. There is no medical indication to continue this therapeutic approach. Other pain management techniques are available.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 extension have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea one-month extension of Integrated Pain Management
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea paravertebral facet joint injection forthe 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 records do not show the indicated type of pain.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 there is no recent MRI. There are multiple other pain generators documented, but not addressed. The facet joint exam with range of motion and loading tests is not documented. The requested procedure is 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-approvea paravertebral facet joint injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard colorectal cancer screening testing.
You asked the Plan to pre-approve Cologuard test. You say that due to COVID-19 you do not want to go into
the provider's office unless you need to, and the Cologuard test is an easy way for you to do this instead. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do
not meet the Medicare criteria for Cologuard testing.
The Plan must follow Medicare rules. Medicare rules say that the Cologuard colorectal screening test is only
covered for enrollees who are age 50 to 85, asymptomatic, and at average risk of developing colon cancer.
We looked at the file and Medicare rules. You are not between the ages of 50 to 85, and you are not
asymptomatic due to your history of blood in stool. Based on this information, we decided that Medicare rules
for coverage of Cologuard test have not been met. Therefore, we decided that the Plan does not have to preapprove
Cologuard colorectal cancer screening testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.You asked the Plan to pre-approve Eliquis. 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 a covered 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 Eliquis.Benefits for Eliquis may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
You asked the Plan to pre-approve a home ventilator (E0466). You say that a home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee did not meet guidelines for the requested home ventilator
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee was recently hospitalized. There is no documentation of COPD with pulmonary function tests, and there are no arterial blood gas data obtained while the enrollee is in a stable state. Medicare does not cover a home ventilator when used as BiPAP, nor when used in the treatment of obstructive sleep apnea. This enrollee's needs may be met with CPAP or BiPAP. There is no evidence of BiPAP failure. A home ventilator is not medically necessary, and the denial is upheld.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 24, 2020.
You asked the Plan to pay for the office visit. 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 payable.
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 99202 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. 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 low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99202 is not supported in the medical record. Specifically, this service was billed with the place of service 21 (inpatient hospital). This code is not payable in this place of service. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 85025) provided to the enrollee on December 18, 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 Current Procedural Terminology (CPT) code 85025-59 remains not supported.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 85025 is "Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count."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 services at issue in this case were not coded correctly. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).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 (CPT 85025) provided to the enrollee on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee on September 3, 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 Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported.
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 G0481 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; 8-14 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 reviewer says that the records do not support the coding of HCPCS G0481 Our physician reviewer found there is no documentation of an established relationship of the provider and patient and no records are submitted of the testing results. 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 drug testing services (HCPCS G0481) provided to the enrollee on September 3, 2019.
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 waive the copayment forthe arthrocentesis provided on February 3, 2020.You asked the Plan to waive the copayment forthe arthrocentesis. You say that you were told the hospital was out-of-network but it was paid as in-network. You say you would like the bill reviewed. ThePlan 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 $265 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $265 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the outpatient hospital is an in-network provider.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 forthe arthrocentesis provided on February 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from a short
SNF stay in order to allow for reconditioning. The Plan denied your request. The Plan says there are no therapy
needs and no daily skilled nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found he beneficiary is a 62 year old
female with schizophrenia and psychosis. From a nursing perspective, the beneficiary received oral and topical
medications. The beneficiary had stable vital signs. She was monitored for vaginal bleeding. Regarding
rehabilitation services, the beneficiary received PT in the acute hospital. The beneficiary was independent with
transfers and was able to ambulate 150 feet at a with a rolling walker.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a
skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab tests provided on February13, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab tests. 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 atissue 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 forlab tests provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral surgery provided to the enrollee on March 10, 2020 by a
non-contracted provider.
You asked the Plan to pay for oral surgery. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says oral surgery services are excluded from coverage in
accordance with the 2020 Evidence of Coverage, 2020 Dental Certificate of Coverage and your Optional
Enhanced Dental package benefit documents.
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, the requested items or services are not
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for oral surgery provided to the
enrollee on March 10, 2020 by a non-contracted provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac computed tomography (CT) services.
You asked the Plan to pre-approve the cardiac CT scan. You say that the records provided support the need for
the requested CT scan. The Plan denied your request. The Plan says the requested study is not 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 cardiac CT scan. Our reviewer says
that the requested cardiac CT scan is not medically necessary. Our physician reviewer found the enrollee's LDL
cholesterol level was 230 mg/dL, which is very high. Current JACC guidelines state that with levels of 190
mg/dL or higher warrant maximal tolerated statin with consideration for adding ezetimibe and/or PCSK9-I. In
this clinical setting, the enrollee's treating physician intended for the Cardiac CT calcium score to help decide if
her hyperlipidemia should be treated with medication. However, guidelines do not support this test being
helpful to significantly reduce risk of atherosclerotic events as the enrollee is already at significant elevated risk
with the current cholesterol levels. There was no other evidence provided supporting another indication for this
testing 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 cardiac CT scan have not been met. Therefore, we decided that the Plan
does not have to pre-approve cardiac computed tomography (CT) services.
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's needs are being met in the current setting. The LTACH will not provide additional services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee requires too much care for a longterm
care facility. You say that the enrollee requires more can than she is able to be given at home. The Plan
denied your request. The Plan says SNF care is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications,
had stable vital signs, and was diagnosed with toxic-metabolic encephalopathy. The enrollee received physical
therapy and occupational therapy in the acute hospital. The enrollee was 2-person minimal assist level with be
mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled
therapy service needs. There are no identifiable skilled nursing service needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.