Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on July 2, 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 office visit (99212) rendered by the out-of-network (OON) provider on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an out-of-network oncology referral.  You asked the Plan to pay for the referral. You say that the requested provider is best equipped to treat your cancer. The Plan denied your request. The Plan says the requested provider is outside of the plan's network, and not uniquely qualified to treat prostate cancer.  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 an out-of-network oncology referral.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Enbrel SureClick.  You asked the Plan to pre-approve Enbrel SureClick. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested drug is not among those covered under the enrollee's medical 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 Enbrel SureClick.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an arthrocentesis injection (20611) provided on June 4, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an arthrocentesis injection. You say that this patient saw the provider for left hip pain and was treated. The Plan denied your request. The Plan says this provider is a non-participating provider and there is no referring provider. The Plan also says that they did not authorize any services for this provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 an arthrocentesis injection (20611) provided on June 4, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aveed.  You asked the Plan to pre-approve Aveed. 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 medically necessary.  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 Aveed. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of testicular hypofunction. There is no documentation that Aveed meets Medicare criteria for medically reasonable and necessary for the enrollee. Provided records do not document low total or free testosterone levels on laboratory testing. Total testosterone levels range from 332 to 384 ng/dL and free testosterone levels are 68 pg/mL; all of these values are within the normal range. Therefore, the enrollee does not meet criteria for the requested drug.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aveed have not been met. Therefore, we decided that the Plan does not have to pre-approve Aveed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you would like an IRF admission covered. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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.  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: 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 you cannot go home without doing transitional care. The Plan denied your request. The Plan says you do not have skilled nursing or therapy needs that can only be provided on an inpatient basis.  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 services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a contact guard assist level for functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient psychiatric admission to be provided by an out-of-network provider.  You asked the Plan to pre-approve an inpatient psychiatric admission. You say that continuation of acute increased psychiatric hospitalization for treatment and management of the members schizophrenia is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a less restrictive lower level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 an inpatient psychiatric admission. Our reviewer says that an admission is not medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care. Our physician reviewer found the enrollee did not show any abnormal behaviors or any symptoms which would require acute treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xarelto.  You asked the Plan to pre-approve Xarelto. You say that the enrollee tried Eliquis from September 11, 2019, to January 8, 2020. You also say that the enrollee has been taking Xarelto since January 9, 2020. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.  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 Xarelto.   Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for blood smear interpretation (85060) provided on August 30, 2021.  You asked the Plan to pay for blood smear interpretation. You say that this procedure was rendered in the appropriate place of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because no payment is made for code 85060 if furnished to hospital outpatients.  The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients.     We looked at the file and Medicare rules. This code is not payable when furnished on a hospital outpatient basis. Based on this information, we decided that Medicare rules for coverage of blood smear interpretation have not been met. Therefore, we decided that the Plan does not have to pay for blood smear interpretation (85060) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wound care services.  You asked the Plan to pre-approve the requested services. You say that a skin substitute would encourage closure of the wound. The Plan denied your request. The Plan says the enrollee's wound is improving with conservative wound therapy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   The file shows that Kerecis Omega3 wound care services were requested. 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 services. Our physician reviewer found that in this case, the record indicates the enrollee has a diabetic foot ulcer due to pressure and thermal injury. The record indicates that the ulcer is healing with standard wound therapy. The wound is at a nearly 50% decrease in size on two consecutive visits is noted. The record provided does not establish the medical necessity and reasonableness of the requested service.    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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction rendered on November 17, 2021.  You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the services are not covered.  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 up to $550 per calendar year for supplemental routine vision services.  We looked at the file and the Plan's rules. The file shows that the eye refraction was not part of a routine eye exam, but a medical exam. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Eye refractions are also not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the eye refraction rendered on November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Denosumab (J0897).  You asked the Plan to pre-approve Denosumab. The Plan denied your request. The Plan says the criteria for approval are not met as there does not appear to have been a trial, intolerance or contraindication to Zoledronic Acid or Pamidronate.  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 Denosumab. Our reviewer says that Denosumab (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drugs, Zoledronic Acid or Pamidronate. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab (J0897).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the molecular genetic screening provided on March 24, 2021.  You asked the Plan to pay for the molecular genetic screening. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The documentation does not include the results of a prior prostate biopsy. In addition, there was no documented significant interval increase in prostate specific antigen (PSA) level. This means the molecular genetic screening at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular genetic screening provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on September 2, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The targeted genomic sequence analysis panel at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0480 provided on February 1, 2021.  You asked the Plan to pay for the drug testing. 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 supported by the documentation.  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 G0480 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; 1-7 drug class(es), including metabolite(s) if performed.  We find that CPT code G0480 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 provided on February 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra 5% drops, for the enrollee.  You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says Xiidra is a self-administered drug. The Plan states the enrollee does not have pharmacy benefits administered by the health plan.  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 Xiidra 5% drops, for the enrollee.   Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.