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

 We decided that the Plan does not have to waive the deductible for a magnetic resonance imaging (MRI) test provided on September 10, 2021.  You asked the Plan to waive the deductible for an MRI. You say that you were told this service would only cost $200. The Plan denied your request. The Plan says the deductible applied was correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to advanced imaging services provided in an outpatient hospital setting.   At the time of the service, you had paid $201.20 towards your $750 deductible. The allowed amount of this claim was $828.92. You are being asked to pay $548.80 towards meeting your deductible ($750 - $201.20 = $548.80). The remaining amount of the claim is $280.12, resulting in a copayment of $200, for a total of $748.80. ($750 - $201.20 = $548.80) deductible + $200 copayment = $748.80 enrollee responsibility.  The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to advanced imaging services provided in an outpatient hospital setting. The Plan has also followed Medicare rules by clearly disclosing in the contract that there is a $200 copayment after meeting this deductible. This cost sharing is a contractual obligation that had not been met at the time an MRI was received on September 10, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a magnetic resonance imaging (MRI) test provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on September 2, 2021.  You asked the Plan to pay for the dental services. You say that you went to the dentist for a cleaning. You say that it was the fastest cleaning you had ever had. You also say that you feel you should not be responsible for the $65 charge as you did not have your teeth cleaned. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services.  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 periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on July 10, 2020, through July 15, 2020 and billed with Patient Driven Payment Model (PDPM) code IGEC1 x 5 days.  You asked the Plan to pay for the SNF services billed with PDPM code IGEC1 x 5 days. You say that you would like reconsideration because the documentation supports the PDPM score billed. The Plan denied your request. The Plan says the documentation does not support the nursing component of the PDPM score billed by showing that Parenteral IV fluids administered, were specifically for nutrition or hydration.  The Plan follows Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS).  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 SNF services billed with PDPM code IGEC1 x 5 days. Our reviewer says that the documentation submitted does not support the PDPM code billed. Our physician reviewer found the documentation does not support the nursing component of the PDPM score billed by showing that Parenteral IV fluids were specifically for nutrition or hydration.  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 services billed with PDPM code IGEC1 x 5 days have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on July 10, 2020, through July 15, 2020 and billed with Patient Driven Payment Model (PDPM) code IGEC1 x 5 days.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continued Skilled Nursing Facility (SNF) care.  You asked the Plan to pre-approve the continued SNF care. You say that you would like reconsideration because the continued SNF care is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the continued SNF care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is noted to have limited initiation in therapy. There has been family training. The member does not require ongoing skilled therapy. The member does not require skilled nursing or skilled therapy on a daily basis or as a practical matter on an inpatient basis in a SNF.  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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued Skilled Nursing Facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional office visit (99213) provided on April 30, 2021.  You asked the Plan to pay for an additional office visit. You say that the enrollee was treated for a number of medical conditions. The Plan denied your request. The Plan says this is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that an addition unit of CPT code 99213 is not supported in the medical record. The medical record only supports 1 unit of CPT code 99213. Based on this information, we decided that Medicare rules for coverage of an additional office visit have not been met. Therefore, we decided that the Plan does not have to pay for an additional office visit (99213) provided on April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit.  You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of Retacrit in the setting of iron deficiency anemia has not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary. You have a diagnosis of iron deficiency anemia. The Food and Drug Administration has not stated that the requested drug is indicated for your condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in your clinical situation. Our physician reviewer found that your condition does not meet criteria for coverage of Retacrit.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rituxan 100MG/10ML vial (CPT code J9312) from January 5, 2022, through January 4, 2023, for 40 NDC Units, for the enrollee.  You asked the Plan to pre-approve the medication. You say that this medication is medically necessary for the use of rituximab or bioequivalent due to the enrollee's recurrent Bickerstaff encephalitis with positive GQ B1 antibody. You state the enrollee has had two (2) attacks now and is also not back to their baseline and at risk for further attacks. You state that you currently have the enrollee on prednisone but feel that they need further immunosuppression (illegible text) need for repeat acute immunotherapy, and possibly even death. The Plan denied your request. The Plan says review of current medical literature fails to reveal any evidence that rituximab is safe and effective. The Plan states there have been two case reports of its use for this disorder. The Plan states case reports cannot determine efficacy as negative outcomes are rarely reported and there have been no prospective clinical trials supporting the efficacy of rituximab in this disorder.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 medication. Our physician reviewer found the record indicates that the enrollee has a diagnosis of Bickerstaff encephalitis. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan 100MG/10ML vial (CPT code J9312) from January 5, 2022, through January 4, 2023, for 40 NDC Units, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 10, 2021.  You asked the Plan to pay for the laboratory services. 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 a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from January 23, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that you are not ready to go home yet and do not want to end up in the hospital again. The Plan denied your request. The Plan says you exceed mobility and activities of daily living criteria for SNF admission. The Plan states you would be equally well served at an alternative level of care, such as discharge to home with Home Health Care (HHC) services and family assistance as needed. The Plan states you do not require daily skilled therapy services due to your high level of function.  The Plan states the skills of a licensed therapist are not medically necessary for stand by assist of your walking, transferring or activities of daily living needs. The Plan states this level of assistance may be provided by unskilled people in your own home with continuation of therapy through Home Health Services.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of January 22, 2022, you did not require any skilled nursing or rehabilitation services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of January 22, 2022. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your functional improvement had plateaued by January 22, 2022, and you did not require any further inpatient skilled rehabilitation services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of January 22, 22, 2022, you required custodial services. The denial for further inpatient skilled care 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from January 23, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (11056) provided on June 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion. You say that you are appealing with supporting records. The Plan denied your request. The Plan says you are a non-network provider with the member's health plan and no necessity for an out-of-network provider, such as an urgent or emergency situation has been documented.  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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (11056) provided on June 14, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay was medically necessary. You state the enrollee would be at risk of not regaining strength if sent to a lower level of care and would be at risk of readmission. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states the services the enrollee requires of skilled therapy, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the chest (71046) provided August 12, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as they were billed incorrectly. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $100 copayment for Outpatient hospital services.        You have been asked to pay an $80.62 copayment for an x-ray, which is less than the $100 stated in the Plans contract. X-rays fall within the Outpatient hospital services 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 an x-ray of the chest (71046) provided August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on September 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for lab services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 15, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight psychotropic test provided to the enrollee on June 19, 2021.  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 the records do not document anxiety or major depressive disorder.  The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of GeneSight testing.  Medicare does not currently consider the denied testing to be reasonable or necessary. 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 GeneSight psychotropic test provided to the enrollee on June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve in-network benefit coverage for a power wheelchair and accessories to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve in-network benefit coverage for a power wheelchair and accessories to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 in-network benefit coverage for a power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lucentis (J2778).  You asked the Plan to pre-approve Lucentis. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the documentation does not indicate that the enrollee has not demonstrated a positive clinical response to bevacizumab.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Lucentis. Our reviewer says that Lucentis is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the ophthalmic formulation of bevacizumab. The reviewer found that there is no indication that the plan's required drug has been less effective or has caused adverse effects for the enrollee. Therefore, the reviewer found that requested drug is not medically necessary as the step therapy criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Specifically, the file shows that the enrollee has not tried and failed the Plan's preferred drug. Therefore, we decided that the Plan does not have to pre-approve Lucentis (J2778).