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

We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on January 18, 2021.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0483 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on January 18, 2021, and received by the lab on January 19, 2021. Of note, the patient resides in Alabama (AL) and the billing laboratory is located in Florida (FL); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on January 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zirabev and Gemcitabine for the enrollee.

You asked the Plan to pre-approve Zirabev and Gemcitabine. You say that this is medically necessary for the
enrolllee. The Plan denied your request. The Plan says that the drug regimen is not being prescribed for a
medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Zirabev and Gemcitabine. Our reviewer
says that Zirabev and Gemcitabine are not medically reasonable and necessary. Zirabev and Gemcitabine are
not FDA-approved for the enrollee's diagnosis. The use of Zirabev and Gemcitabin are not supported by one of
the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for
coverage of Zirabev and Gemcitabine.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zirabev and Gemcitabine have not been met. Therefore, we decided that the
Plan does not have to pre-approve Zirabev and Gemcitabine for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary for the treatment of
multiple myeloma. The Plan denied your request. The Plan says the criteria is not met.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found daratuzumab is FDA
approved for the treatment of relapsed or refractory multiple myeloma (as monotherapy) in adults who have
received at least 3 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent or
who are double refractory to a proteasome inhibitor and an immunomodulatory agent. This enrollee has only
received one prior line of therapy. Monotherapy as a 2nd line is not supported by the medical literature or the
National Comprehensive Cancer Network (NCCN) guidelines. The documentation does not support that this
drug would be safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Darzalex for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you do not need three hours a day of therapy and your medical illnesses
are stable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and
atrial fibrillation and were discharged to skilled nursing on November 22, 2021, then to long term care on
December 27, 2021. There is ongoing weakness. Your medical problems are stable. There are no complex
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have 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 you will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition
does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, and 84100) provided to the enrollee on April 7, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider reported routine lab services related to the treatment of end stage renal disease (ESRD), which does not follow industry standard coding rules. The Plan states the documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of ESRD; therefore, in accordance with Centers for Medicare & Medicaid Services (CMS), the laboratory tests are the responsibility of the dialysis center and are not separately reportable by the laboratory.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows there is no modifier to indicate this would be separate from ESRD.
The medical records also indicate that these laboratory services were related to ESRD. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, and 84100) provided to the enrollee on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an electrocardiogram and transthoracic echocardiogram provided on August 10, 2021, and August 11, 2021.

You asked the Plan to waive the coinsurance for the electrocardiogram and transthoracic echocardiogram. You say that the coinsurance should be covered as the services were provided in-network The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% and 20% coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a 20% coinsurance for the electrocardiogram services provided on August 10, 2021 (the total allowed amount is $17.32 x 20% = $3.5). You have also been asked to pay a 20% coinsurance for a transthoracic echocardiogram provided on August 11, 2021 (the total allowed amount is $536.71 x 10% = $53.7). The record indicates that the services were performed out-of-network. Electrocardiograms fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an electrocardiogram and transthoracic echocardiogram provided on August 10, 2021, and August 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 these services are medically necessary. The Plan
denied your request. The Plan says that you do not require intensive therapies or full time access to a doctor.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care.

You were admitted for weakness and non-surgical management of a subdural hematoma after a fall. Your
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While you have 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 you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra test strips for the enrollee.
You asked the Plan to pre-approve OneTouch Ultra test strips. You say that these are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that glucose monitors and related accessories and supplies are only covered if the enrollee has diabetes.
We looked at the file and Medicare rules. The file indicates the enrollee does not have diabetes. Based on this information, we decided that Medicare rules for coverage of OneTouch Ultra test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra test strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does have to pay for the crowns (D2740) for teeth # 8 and 9 provided on June 4, 2021.

You asked the Plan to pay for the crowns. You say that 2 of the 4 crowns that you received were covered. You say that your teeth were in bad condition. You also say that you called before the date of service and were advised they would be covered by your insurance. The Plan denied your request. The Plan says the services exceed the benefit.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan denied the services based on criteria that would require x-rays to make a decision. There were no x-rays provided in the case file. Additionally, x-rays were requested but not received. Without x-rays we are not able to verify if the Plan was correct in denying payment for these services. Therefore, we decided that the Plan does have to pay for the crowns (D2740) for teeth # 8 and 9 provided on June 4, 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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

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. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Cyclosporine Modified.
You asked the Plan to pre-approve a tier exception for Cyclosporine Modified. 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 Cyclosporine Modified have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Cyclosporine Modified.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 the admission.

Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, it is not expected that this enrollee would improve in a reasonable period of time, as she does not have dangerousness to self or others, and was not showing any auditory/visual hallucinations or any aggressive behaviors. It does not appear medically reasonable or necessary to have psychiatric care provided at the acute inpatient level of care, rather than a lower level of care. It does not appear that active treatment is taking place. The health plan's denial of inpatient psychiatric services appears appropriate. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110-GP, CQ, KX (4 units)) provided to the enrollee on January 13, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this CPT code is not supported and there is a more appropriate healthcare common procedure coding system (HCPCS) code G0157 for the billed service.

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 asked our coder 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 the service. Our reviewer found documentation submitted was reviewed, and DOES NOT MEET CRITERIA. Documentation does support physical therapy services provided in the home due to the enrollee being home bound. The therapist performing services was a Physical Therapy Assistant (PTA). There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for services provided in the home. CPT 97110 is an inappropriate code to report for
service documented. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110-GP, CQ, KX (4 units)) provided to the enrollee on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that a home mechanical ventilator set in AVAPS mode that could be delivered by 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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. The enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support capability. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on October 14, 2021.

You asked the Plan to pay for the resin-based composites. You say that the entire dental team has recommended these dental procedures as medically necessary for future treatment. You say that the member was eligible for benefits and the services rendered are covered. The Plan denied your request. The Plan says care rendered by a provider that is not part of our supplemental dental network is not covered.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided on October 14, 2021.