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

 We decided that the Plan does not have to pre-approve Syn-One genetic testing.  You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this is not medically necessary.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the medical necessity of Syn-One biopsy is not justified. This test remains investigational, and CMS has not completed a technical assessment necessary to establish medical coverage for this test. The clinical validity and clinical utility of this test are still in process. This test will not provide any clinical value for the patient and has no prognostic value.       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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Syn-One genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cervical epidural steroid injections.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met. The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical indications.   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 there is no documentation of failure to respond to 4 weeks of noninvasive conservative care or inability to tolerate non-invasive conservative therapy. There is also no documentation of functional impairment. In this case, the clinical information provided does not meet the coverage criteria and, therefore, the requested epidural steroid injection is not indicated at this time. Therefore, the requested cervical epidural steroid injection is 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient hospital care.  You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a right reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for COVID-19 home tests provided on  October 3, 2021.  You asked the Plan to reimburse you for COVID-19 home tests. You say that you are going on several cruises and need to be tested. The Plan denied your request. The Plan says based on the member's benefit plan and the Pick Your Perks program; COVID-19 home tests are not covered.  The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list.  We looked at the file and the Plan's rules. The file shows that over-the-counter items must be included on the Plan's allowed items list. COVID-19 home tests are not on the allowed items list and not covered. Therefore, we decided that the Plan does not have to reimburse you for COVID-19 home tests provided on  October 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on April 19, 2021.  You asked the Plan to pay for ConfirmMDx testing. You say that this is a covered service. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.  We looked at the file and Medicare rules. The records do not show that the enrollee underwent a previous biopsy or is being considered for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on April 19, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency services (procedure code 99284) provided to the enrollee on July 20, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no additional information to support the billing method on this claim.  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 99284 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function."  We find that CPT code 99284 is not supported in the medical record. Specifically, the case file did not contain medical records for the billed services. It cannot be determined if the code was substantiated in this case. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency services (procedure code 99284) provided to the enrollee on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral x-ray, cone beam CT capture and consultation provided on July 31, 2021.  You asked the Plan to pay for the intraoral x-ray, cone beam CT capture and consultation. You say that you want to appeal the denial of the claim. The Plan denied your request. The Plan says reimbursement for one intraoral x-ray has already been issued and the cone beam CT capture and consultation are not covered benefits.  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, you also have a maximum benefit of one intraoral x-ray per calendar year. The plan paid for the intraoral x-ray provided on June 30, 2021, which exhausted your benefit. The cone beam CT capture and consultation remain denied as non-covered benefits. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray, cone beam CT capture and consultation provided on July 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does not meet the requirements for Aduhelm.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Aduhelm. Our physician reviewer found Aduhelm is not Food & Drug Administration (FDA) for the enrollee's diagnosis. Aduhelm is approved for treatment of Alzheimer's Disease (AD) in patients with mild cognitive impairment or mild dementia stage of the disease. The documentation is inconsistent regarding the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Aduhelm.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa.  You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this 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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that the medical records do not show that the patient has had a recent trial and failure of conservative measures for knee pain, including physical therapy. More conservative measures are needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 4 additional occupational therapy visits.  You asked the Plan to pre-approve 4 additional occupational therapy visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 4 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the records do not document why the previously approved therapy plus the 8 additional visits and utilization of the home exercise program are inadequate to treat your condition.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional occupational therapy visits.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips.  You asked the Plan to pre-approve routine transportation. You say that you were told you would have unlimited trips and you depend upon these trips. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation trips is correct, because routine transportation beyond 50 one-way trips per calendar year is not covered by the Plan.  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 50 trips per year.   We looked at your request, the records in the case file, and the rules. 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 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Home Health Aide services for 6 hours a day, 7 days a week.  You asked the Plan to pre-approve the additional Home Health Aide services. You say that you would like reconsideration because you have suffered multiple falls and need assistance for more than the approved 3 hours per day. The Plan denied your request. The Plan says you do not qualify for additional home health aide services because this is considered custodial care.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 additional Home Health Aide services. Our reviewer says that there is no documentation that the services meet the definition of home health aide services.  No documentation of a request for or provision of skilled home health nursing or therapy services has been provided. Our physician reviewer found based on the available medical records there is no documentation that the home health aide services are reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff.  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 additional Home Health Aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Health Aide services for 6 hours a day, 7 days a week.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency anesthesia services (99140) provided on January 13, 2021.  You asked the Plan to pay for code 99140. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Code 99140 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia services (99140) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 7, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to  describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021 by a non-network provider.  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 rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies rendered on May 20, 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 are not covered.  The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. There are no RVUs and no payment amounts for these services, procedure codes with a status indicator of X are statutorily excluded, and payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure codes A4550 (surgical trays) and 99072 (additional supplies, materials, and clinical staff time) have a status indicator of B and no separate Medicare payment. Codes A4556 (electrodes, pair), A4557 (lead wires, pair), and A4649 (surgical supply, miscellaneous) have a status indicator of P and no separate Medicare payment. Code A9999 (miscellaneous dme supply or accessory) has a status indicator of X and is excluded from Medicare payment. 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 supplies rendered on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 15, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 15, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Granix.  You asked the Plan to pre-approve Granix. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Granix. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Neupogen (filgrastim), Nivestym (filgrastim-aafi), and Zarxio (filgrastim-sndz) [2 of 3], would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services you received on July 24, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment has been made for these services.  The Plan must follow Medicare rules. Medicare rules say that there is no balance billing paid by either the plan or the enrollee for services provided by a non-contract provider.  We looked at the file and Medicare rules. The records show that the Plan as made payment to the non-contract provider based on the Medicare allowed amount for these services. The Plan is not required to make any additional payment for the services in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services you received on July 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiation therapy.  You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found intensity-modulated radiation therapy (IMRT) would not be an accepted standard for routine use based on NCCN guidelines and ASTRO model policy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy.