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

We decided that the Plan does not have to pay for SNF services provided from April 12, 2021, through
May 11, 2021.
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says SNF services are not medically necessary.
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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was functioning at his baseline. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from April 12, 2021, through May 11, 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GenVisc.
You asked the Plan to pre-approve GenVisc. You say that this drug is medically reasonable and necessary. The
Plan denied your request. The Plan says step therapy criteria have not been 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 GenVisc. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a
trial of one of the preferred drugs (Visco-3, Gel-One, Orthovisc, Synvisc, or Synvisc One) before they will
approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no
documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely
have adverse effects for the 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 GenVisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve GenVisc.
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 need IRF care and do not want to go to a skilled nursing facility. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 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 not support a need for physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional trips for routine transportation beyond the Plan's 36-trip limit.
You asked the Plan to pre-approve the additional trips for routine transportation. You say that you need additional trips to your treatments. The Plan denied your request. The Plan says you have used all 36 trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 trips per year.
We looked at your request, the records in the case file, and the rules. The Plan provided documentation
showing that you have used all 36 routine transports included in your benefit. Based on this information, we
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore,
we decided that the Plan does not have to pre-approve the additional trips for routine transportation beyond the
Plan's 36-trip limit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenetic testing provided on May 26, 2021.
You asked the Plan to pay for genetic testing. You say that this testing can affect clinical decisions on a patient's substance use. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests must be ordered by a physician treating a beneficiary for specific medical problems and who uses the results in the management of the beneficiary's specific medical problem. Medicare rules say that services provided, ordered, or certified must be authenticated with a handwritten or electronic signature. We looked at the file and Medicare rules. The records of the consultation for this testing were not authenticated by the enrollee's treating physician. Without authenticated records, there is no valid documentation which supports that the ordering provider is treating the enrollee for a specific medical problem for which this testing has been ordered. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing provided on May 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 9, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you need to continue the provider's services 
for continuity of care. The Plan denied your request. The Plan says rules for out-of-network care 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 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on January 9, 2021, by an out-
of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid.
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 Prolia. Our reviewer says that Prolia is
not medically necessary. Our physician reviewer found based on the medical records provided there is no
indication that the enrollee has tried and failed the required drug. The reviewer also found that there is no
indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the
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 Prolia have not been met. Specifically, the file shows that the enrollee has not
tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia
(J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus Solos injections.
You asked the Plan to pre-approve the Lantus Solos injections. You say that the records provided support the need for the drug being requested. The Plan denied your request. The Plan says the enrollee does not have pharmacy benefits administered under this contract.
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 Lantus Solos injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuplazid.
You asked the Plan to pre-approve Nuplazid. You say that this is the only approved medication for hallucinations related to Parkinson's diagnosis. The Plan denied your request. The Plan says this medication is not eligible for coverage under the Part B 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 Nuplazid.
Benefits for Nuplazid 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 the drug test coded G0482 provided on May 5, 2021.
You asked the Plan to pay for the drug test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed.
We find that CPT code G0482 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 test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test
coded G0482 provided on May 5, 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. The Plan denied your request. The Plan says your 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 physician reviewer found that you were admitted to the acute care hospital for a liver and kidney transplant. Your medical problems are stable. You do not require treatment by multiple therapies in 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.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the body from head to thigh for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical evidence to support the request for this scan.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is no strong suspicion of malignancy, which is a requirement for this scan.
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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the body from head to thigh for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing xrays
(D0274) and periapical x-ray (D0220) provided on March 18, 2021.
You asked the Plan to pay for the dental services. You say that it is impossible for a dentist to be considered out
of network. You say that the Evidence of Coverage says out of network dentist have a 20% coinsurance. You
also say that at least some of this bill should be covered. The Plan denied your request. The Plan says the
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to a dentist
that has opted out of Medicare.
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 dental services received by a
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided
that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274)
and periapical x-ray (D0220) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (90785, 90792) provided on May 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Specifically, the record shows that the claim was billed with primary diagnosis code F05. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay for the services (90785, 90792) provided on May 6, 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 you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for IRF service is correct.
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 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. 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 the 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 you are receiving appropriate care at the present acute care hospital. There are no
services available at the LTACH that you require 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