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

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on June 23, 2021.

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 were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing is covered when specific criteria are met. 

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has listed diagnoses of Dysthymic disorder, Generalized Anxiety Disorder, Other stressful life events affecting family and household problems of adjusting to life-cycle transitions. The listed diagnoses on the GeneSight Order Medical Necessity Documentation include Major depressive disorder, recurrent severe without psychotic features, Generalized anxiety disorder, Other stressful life events affecting family and household, and Problems of adjustment to life-cycle transitions. The chief complaint states the enrollee would like to get the testing to see what medications he could tolerate. The records do not support that the GeneSight testing was reasonable and medically necessary to treat the enrollee's diagnoses.

We looked at this physician's review, 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 for the GeneSight Psychotropic Assay rendered on June 23, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that your nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spine surgery. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab.

You asked the Plan to pre-approve pembrolizumab. You say that this is medically necessary. The Plan denied
your request. The Plan says that this treatment is not recommended.

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 pembrolizumab. Our reviewer says that
pembrolizumab is not medically reasonable and necessary. Pembrolizumab is not FDA-approved for your
diagnosis, it is reserved for refractory or recurrent disease. The use of pembrolizumab is not supported by one
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal Our
physician reviewer found that your condition does not meet criteria for coverage of pembrolizumab.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve pembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for low osmolar contrast material (Q9967) provided on June 25, 2020.

You asked the Plan to pay for low osmolar contrast material. You say that this is supported in the records. The Plan denied your request. The Plan says there is a more appropriate code for this material.

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 Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml.

We find that CPT code Q9967 is not supported in the medical record. Specifically, the records show that the contrast material used was Omnipaque 240, which does not fit the description of the billed code. Based on this information, we decided that Medicare rules for coverage of low osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay for low osmolar contrast material (Q9967) provided on June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow.

You asked the Plan to pre-approve these services. You say that you are requesting this to treat shoulder pain.
The Plan denied your request. The Plan says that this is not Food and Drug Administration (FDA) approved.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. This is considered
experimental/ investigational. This medication is not FDA approved for shoulder injection to treat rotator cuff
pathology. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Fluid Flow.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on August 11, 2020, and October 27, 2020.

You asked the Plan to waive the coinsurance for Part B drugs. You say that you have never been charged this much for your injections. The Plan denied your request. The Plan says that coinsurance applied was correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. The allowed amount of these claims total $972.93, resulting in a coinsurance amount of $194.59.

You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B Prescription Drugs 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 coinsurance for Part B drugs provided on August 11, 2020, and October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.

You asked the Plan to pre-approve the PET scan. You say that the scan is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for staging of suspected metastatic prostate cancer for bone disease a bone scan would be the next test rather that a PET scan. A PET scan would be indicated if there was equivocal disease after standard work-up. A PET scan is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 14, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that this was an emergency and there was no way your wife could drive you. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $250 copayment for ambulance services.

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies to both emergency and non-emergency ambulance services. 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 ambulance services you received on April 14, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Capecitabine (J8521).

You asked the Plan to pre-approve Capecitabine. You say that this drug is medically necessary for the enrollee's cancer. The Plan denied your request. The Plan says that the coverage criteria have not been met.

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 Capecitabine. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-year-old female who has been diagnosed with metastatic gallbladder cancer. In this case, the requested drug is not FDA approved for the enrollee's condition. However, the use of the requested drug is supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. Finally, the documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Capecitabine have been met. Therefore, we decided that the Plan has to pre-approve Capecitabine (J8521).

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on May 20, 2021, at an outpatient hospital facility.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you are on a fixed income and you cannot afford to pay this. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $400 copayment for outpatient surgery in an outpatient hospital facility.

You have been asked to pay a $400 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery in an outpatient hospital facility 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 diagnostic colonoscopy you had on May 20, 2021, at an outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on May 6, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthotic device for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of MyoPro orthotic device in the setting of unilateral upper extremity impairment following a stroke has not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee needs to stay in the hospital until he is better.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reimburse you for the balance billing for the specialist office visit and x-ray provided on July 17, 2020. We also decided that the Plan does not have to reimburse you for the coinsurance for the visit and the x-ray.

You asked the Plan to reimburse you for a specialist office visit and x-ray. You say that your doctor wanted a $425 payment for your visit and x-ray. You also say that the Plan told you to pay the $425, and they would reimburse you the entire $425. The Plan denied your request. The Plan says you have been asked to pay 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 45% coinsurance for each visit with an out of network PCP or specialist. Your contract also clearly says that you must pay 45% coinsurance for x-rays per day with an out of network provider. Your contract also clearly says that you cannot be balance billed.

We decided that the Plan has to reimburse you for the balance billing.

The record shows you paid the provider the full charged amount. You are only required to pay the coinsurance amount. Therefore, we decided that the Plan must reimburse you the balance billed amount of $370.30 for the specialist office visit and x-ray ($425 - $32.80 - $21.90 = $370.30).

We also decided that the Plan does not have to reimburse you for the coinsurance amount. 

You have been asked to pay $32.80, which is 45% of the allowed amount for a specialist office visit ($72.89 allowed amount x 45% coinsurance = $32.80). The office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay $21.90, which is 45% of the allowed amount for an x-ray ($48.67 allowed amount x 45% coinsurance = $21.90). The x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct coinsurance 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 reimburse you for the coinsurance for the specialist office visit and x-ray provided on July 17, 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.