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

We decided that the Plan does not have to pre-approve Atezolizumab and Bevacizumab.
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the drug regimen is not a recommended treatment for the enrollee.
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 requested drugs. Our physician reviewer found that the requested use of the drug regimen is not FDA-approved for the enrollee's diagnosis. The enrollee has already received 1st line therapy with Sorafenib. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested drug regimen is not considered medically reasonable and 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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab and Bevacizumab.
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 was most recently admitted with vasovagal near-syncope, orthostasis, and there is evidence of malnutrition. The enrollee is hemodynamically stable. Co-morbid conditions include anorexia and major depression. He has been admitted to a Psychiatric unit for Psychiatric stabilization. Currently, hemodynamics are stable and the enrollee is non-toxic. Functionally, the enrollee is at contact guard assist/supervised. 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, skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly contact guard assist/supervised assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 4, 2020 to February 17, 2020.
You asked the Plan to pay for these services. You say that you would like the claim paid. The Plan denied your request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the HIPPS code. We looked at the file and Medicare rules. The claims were not billed with the required HIPPS code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Please note that the Plan states you will not be held responsible for the charges. Therefore, we decided that the Plan does not have to pay for the home health services rendered from February 4, 2020 to February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea routine eye exam and eyeglasses to be provided by a non-participating provider.You asked the Plan to pre-approvethe out of area eye exam and glasses. You say that you are out of town and are having blurry vision. You need to be able to see an eye doctor to be able to drive home.The Plan denied your request. The Plan says your plan does not offer coverage for out of area routine eye care.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eyewear when it is provided by a network eye care practitioner. We looked at the file and the Plan's rules. You are requested coverage for eye care from a provider that is not participating with your Plan. Based on this information, we decided that the Plan's rules for coverage of the out of area eye exam and glasses have not been met.Therefore, we decided that the Plan does not have to pre-approvea routine eye exam and eyeglasses to be provided by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The
Plan denied your request. The Plan says PCDs used for the purpose of prevention of venous thromboembolism
is not covered.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service. Additionally, PCD defined by code
E0675 are not covered.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift (E2300) and power standing system (E2301).
You asked the Plan to pre-approve a seat lift and power standing system. You say that the requested items are necessary. The Plan denied your request. The Plan says the items are not primarily medical in nature. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift and power standing system have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift (E2300) and power standing system (E2301).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 4, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 drug testing services provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve injections. You say that you would like approval for these services. The Plan denied your request. The Plan says these services can be provided in-network.
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. Therefore, we decided that the Plan does not have to pre-approve injections to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a capsule endoscopy.
You asked the Plan to pre-approve a capsule endoscopy. You say that the requested capsule endoscopy is
medically necessary. The Plan denied your request. The Plan says that the information received is not enough
to meet the guidelines for coverage.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 a capsule endoscopy.
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee underwent EGD on July 6, 2020 in evaluation of globus and
sore throat. Esophageal stenosis was Savary-dilated to 51F, and biopsies were taken of two large polyps in the
duodenum--opposite from and 10cm distal to the ampulla. The use of capsule endoscopy to evaluate for small
bowel tumors distal to the duodenum in this gentleman with known history of pre-cancerous GI pathology is
medically appropriate, medically necessary, and meets accepted procedure indications as provided.
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 capsule endoscopy have been met. Therefore, we decided that the Plan has to
pre-approve a capsule endoscopy.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says acupuncture is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic low back pain (CLBP) meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. The file shows that you are requesting acupuncture services to treat numbness on the top of his left hand and tingling in his left ring finger and little left finger. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services to be provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on March 16, 2020.You asked the Plan to pay fortheCGP testing. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm provided to the enrollee on January 10, 2020.You asked the Plan to pay forthese services. You say that these services should be covered.The Plan denied your request. The Plan says that this procedure is not supported by the medical records submitted.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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.We asked our coderto 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 these services. Our reviewer says that CPT code 14301 does not meet criteria for billing or reimbursement consideration. Our coderfound that the medical records provided do not include documentation to validate that 14301 was performed as a separate procedure, therefore this service cannot be validated.We looked at this coder'sreview, the file, and Medicare rules. 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 forthe adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm provided to the enrollee on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by an out-of-network provider on February 18, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $30 copayment for physician/practitioner services/in-network/provider services/specialist. You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/in-network/provider services/specialist 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 a specialist office visit provided by an out-of-network provider on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune Luadevice for the enrollee.You asked the Plan to pre-approve an Optune Lua device. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is statutorily not covered by CMS for this enrollee's clinical diagnosis.The Plan must follow Medicare rules. Medicare rules say that the use of tumor treatment field therapy for any indications other than newly diagnosed Glioblastoma Multiforme will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file indicates that the Optune Lua is not being requested for the treatment of newly diagnosed Glioblastoma Multiforme. Based on this information, we decided that Medicare rules for coverage of an Optune Lua device have not been met.Therefore, we decided that the Plan does not have to pre-approvean Optune Lua device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pulse oximeter.You asked the Plan to pre-approvea pulse oximeter. You say that your physician recommended a pulse oximeter due to your medical conditions.The Plandenied your request. The Plan says this device is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare does not cover pulse oximeters.Therefore, we decided that the Plan does not have to pre-approvea pulse oximeter
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 15, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on January 15, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve a home health evaluation.
You asked the Plan to pre-approve the home health evaluation. You say that you believe that you need skilled care in the home including possible physical and occupational therapy. The Plan denied your request. The Plan says that there is no evidence that you require skilled care so you do not meet the criteria to be evaluated for home health services.
Please note that the Plan's denial was in regards to specific home health services such as skilled nursing/skilled therapy; however, the file indicates that only a single evaluation was requested and no actual skilled services were submitted for approval at this time.
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 the home health evaluation. Our reviewer says that the documentation supports the medical necessity of a home health evaluation. Our physician reviewer found the enrollee is a 69-year-old man with a history of heart disease, diabetes, hypertension, COPD, and cirrhosis. The enrollee states that he needs assistance him bathing and dressing, stating he cannot it on his own. He notes that he lives in a 2-story home and it is difficult for him to be mobile. The enrollee states he has fallen twice, and cannot go up or down the stairs. He uses a walker because he cannot walk more than 50-steps without his legs getting swollen because they retain a lot of water. The enrollee states he is has lung issues requiring oxygen, and is diabetic and needs help. The enrollee has multiple medical problems and the documentation supports that a home health evaluation would be reasonable and necessary in this case, to evaluate the enrollee's 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 the home health evaluation have been met. Therefore, we decided that the Plan has to pre-approve a home health evaluation.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approvehome health aide services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the services are not medically necessary. Our physician reviewer found youare not home bound, based on your ability to attend an in-office doctor appointment. There is no evidence that you require skilled in-home registered nurse (RN), physical therapy (PT) or occupational therapy (OT) services. Therefore, there is no evidence that you qualify for concomitant home health aide (HHA) services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from January 1, 2020 to January 25, 2020.
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 there are no valid HIPPS codes on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that the services are not supported in the medical record. Specifically, there are no valid HIPPS code to be found on the claim. 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 skilled nursing facility (SNF) services provided to the enrollee from January 1, 2020 to January 25, 2020.