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 10, 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 testing was 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 testing was not medically necessary. Our physician reviewer found the enrollee has a history of major depressive disorder, panic disorder, and adjustment disorder with mixed anxiety and depressed mood for which she has been receiving mental health counseling and psychotropic medication. The documentation is inconsistent regarding the drug or drugs that the clinician is considering using being reasonable and necessary for the treatment of the enrollee's diagnosis. The testing was 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 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 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagogastroduodenoscopy, flexible, transoral, with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) (43270) esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance (43236) esophagogastroduodenoscopy, flexible, transoral, with biopsy, single or multiple (43239) provided February 19, 2020.
You asked the Plan to pay for the surgical procedures. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service billed.
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, we find that CPT codes 43270, 43236 and 43239 are not supported in the medical record. Specifically the medical records submitted did not include documentation of esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) (43270) does not include a procedure report for esophagogastroduodenoscopy, flexible, transoral (43239) and does not include a procedure report for esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance (43236). Since there is a CCI conflict between 43270 and the codes, the component codes 43239-59 and 43236-59 nor the use of modifier 59 cannot be reviewed. The plan made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the surgical procedures have not been met. Therefore, we decided that the Plan does not have to pay for the esophagogastroduodenoscopy, flexible, transoral, with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) (43270) esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance (43236) esophagogastroduodenoscopy, flexible, transoral, with biopsy, single or multiple (43239) provided February 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transports provided from May 7, 2021, through May 15, 2021.

You asked the Plan to waive the copayment for ambulance transports. You say that you are on a fixed income and would like to claim a hardship. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for each one-way ambulance transport. 

The enrollee has been asked to pay a $200 copayment for each ambulance transport. Ambulance transports falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transports provided from May 7, 2021, through May 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 16, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for office visit. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 office visit provided on November 16, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the annual wellness visit (G0439) provided on April 1, 2021.

You asked the Plan to waive the copayment for the annual wellness visit. You say that you would like reconsideration because you do not believe there should be a copayment for your annual wellness visit. The Plan denied your request. The Plan says you are responsible for 30% of the total allowed amount for an annual routine physical exam when using an out-of-network provider.

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 30% coinsurance for Annual Wellness Visit. 

You have been asked to pay $38.98. The allowed amount for this service is $129.95. 30% of $129.95 is $38.98. You have been asked to pay the correct coinsurance. 

You have been asked to pay 30% coinsurance for the annual wellness visit. 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 annual wellness visit (G0439) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injections (CPT code(s): 64494-50, 64494-50, and 64493-50).

You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says the documentation sent to the Plan did not show that you had enough pain relief from the first shot.

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 injections. physician reviewer found the degree of pain relief was only 50% from the first set of injections; this does not meet the LCD criteria of 80%. Therefore, the request is considered not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injections (CPT code(s): 64494-50, 64494-50, and 64493-50).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Yupelri.

You asked the Plan to pre-approve a tier exception for Yupelri. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.

The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Yupelri have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Yupelri.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% drops.

You asked the Plan to pre-approve Xiidra. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not 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 Xiidra 5% drops.

Benefits for Xiidra 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. 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.

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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. There are no required medical services in the LTACH that the enrollee is not already receiving in the current approved setting. There is no advantage to the requested transfer.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for the requested LTACH services. 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 they are 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 hospital recommended that you have these
services and you are a fall risk. You need inpatient rehabilitation to recover fully and return home safely. The
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your nursing, medical
management and rehabilitation needs can be met at a lower level of 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. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 6, 2021.

You asked the Plan to pay for the office visit. You say that this was a separate service. The Plan denied your request. The Plan says the billed code is part of the global surgical fee that was billed by the same provider.

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 CPT code 99213 is included in the 90-day global surgical period for the surgery provided on April 20, 2021. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient mental health stay provided by an out-of-network provider on February 17, 2021, to February 20, 2021.

You asked the Plan to pay for an inpatient mental health stay. You say that this inpatient admission was medically necessary. The Plan denied your request. The Plan says treatment needs could have been met at a less restrictive setting.

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 pay for inpatient mental health stay. Our reviewer says that this enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. Our physician reviewer found this enrollee was not shown to be a danger to himself or others but was without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. 

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 mental health stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient mental health stay provided by an out-of-network provider on February 17, 2021, to February 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.

You asked the Plan to pre-approve the home ventilator. You say that this ventilator is to be used for the
treatment of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The Plan
denied your request. The Plan says a home mechanical ventilator set in average volume assured pressure
support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician
reviewer found the home ventilator is not medically necessary. This enrollee was recently admitted with acute
hypercarbic respiratory failure, in pulmonary edema. The enrollee improved with dialysis and nocturnal
BiPAP. Obesity-hypoventilation syndrome (OHS) and obstructive sleep apnea (OSA) were suspected; the
enrollees' body mass index (BMI) was 51. Severe pulmonary hypertension was found on echocardiography.
There is mention of COPD in some notes, but there is no information to support this diagnosis. There is no
arterial blood gases (ABG) while the enrollee is stable to document chronic carbon dioxide (CO2) retention.
Medicare does not cover a home ventilator in the treatment of OHS or HFpEF. The enrollee may benefit from
CPAP or BiPAP at night, if OHS and/or OSA are diagnosed. The denial is upheld. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does not have to preapprove
the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of follicular lymphoma. She has not tried and failed the Plan's required drugs, Rituxan, Ruxience, or Riabri. The records do not show that the required drugs would be contraindicated or less effective; therefore, Truxima 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA2 genetic testing.

You asked the Plan to pre-approve BRCA2 genetic testing. You say that the records provided support the need
for the requested genetic testing services. The Plan denied your request. The Plan says the requested genetic
testing services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that in order for tier 1 or tier 2 molecular pathology
procedures to be covered, results of the testing must directly impact treatment or management of the Medicare
beneficiary.

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 BRCA2 genetic testing. Our reviewer
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has no known
malignancy. The requested testing 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 BRCA2 genetic testing have not been met. Therefore, we decided that the Plan
does not have to pre-approve BRCA2 genetic testing.