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

We decided that the Plan does not have to pay for infectious agent disease testing (87631) provided on October
1, 2020.

You asked the Plan to pay for infectious agent testing. You say that you have no knowledge of patient coverage
prior to the specimen's arrival at your laboratory. The Plan denied your request. The Plan says the denial of
payment for this testing is correct, because there is a more appropriate code to describe the service provided
and multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules say that respiratory viral panels of 6 or
more pathogens are non-covered.

In this case, the CPT Code Manual definition of code 87631 is infectious agent detection testing by nucleic
acid; respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified
probe technique, multiple types or subtypes, 3-5 targets.

We find that CPT code 87631 is not supported in the medical record. Specifically, the record shows that this
testing involved more than 3-5 targets. Multiplex PCR respiratory viral panels of 6 or more pathogens are noncovered.
Based on this information, we decided that Medicare rules for coverage of infectious agent testing
have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent disease testing
(87631) provided on October 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 22, 2021,
to March 26, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the reason for admission was for a
lumbar drain trial. You say that the member met the two midnight rule guidelines. The Plan denied your
request. The Plan says this was authorized as outpatient status only.
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 rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that if another procedure was needed or if there were complications inpatient management could have
been requested later. Our physician reviewer found at the time of admission, the patient was hemodynamically
stable without expectation to require hospital services that would likely cross two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided on March 22, 2021, to March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic surgery services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you need this provider to evaluate your current problem. The Plan denied your request. The Plan says you can be cared for in your basic network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The file shows that you have ow back pain affecting the left lower extremity. The requested provider in this case is not in your basic network with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. There are insufficient medical records to show that a higher level of care is needed to treat your condition.

We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve orthopedic surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara.
You asked the Plan to pre-approve Stelara. You say that this drug is medically reasonable and necessary for the
enrollee's condition. 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 Stelara. Our reviewer says that this drug
is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Humira
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 Stelara have not been met. Therefore, we decided that the Plan does not have to
pre-approve Stelara
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 you do 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 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: 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 these services for extra supervision during
your exercises as you are a fall risk. The Plan denied your request. The Plan says the criteria for admission to
an IRF are not met. You can safely receive the care you need in a less intensive setting.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are ready to move to a lower level of care, but you are not ready to go home. The Plan denied your request. The Plan says you can continue to receive appropriate services at the inpatient rehabilitation facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you do not require skilled nursing services of a professional nurse to provide treatment in a SNF. Your feeding tube is noted as not being used. The dressing to the trachea stoma has been clean, dry, and intact. Your functional level does not require skilled therapy services of a qualified therapist to provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services on a daily basis in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. Your needs are being met safely and effectively in the inpatient rehabilitation facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for ambulance transport provided on December 3, 2020.
You asked the Plan to reduce the copayment for ambulance transport. You say that you could have driven yourself to the hospital, but you were not given the opportunity to choose. 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way ambulance trip. You have been asked to pay a $250 copayment for ambulance transport. Ambulance transport falls within the Ambulance Services 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 reduce the copayment for ambulance transport provided on December 3, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.
You asked the Plan to pre-approve Xgeva. You say that this drug is medically 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 Xgeva. Our reviewer says that this drug
is not medically reasonable and necessary. Our physician reviewer found The Plan requires a trial of
intravenous pamidronate or zoledronic acid 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) 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to
pre-approve Xgeva
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab.
You asked the Plan to pre-approve Nivolumab. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met in this case as there are better options that have shown better data for success in treating the enrollee's condition.
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 Nivolumab. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 74-year-old who has been diagnosed with kappa light chain myeloma. In this case, Nivolumab is not FDA-approved for the enrollee's diagnosis. In addition, the use of Nivolumab is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. Studies to date have shown disappointing results with single agent Nivolumab.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 8, 2020.

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 diagnosis codes are not covered.

The Plan must follow Medicare rules. The rules say that any diagnosis code not listed as supporting medical necessity does not support medical necessity for procedure codes 95939, 95938, 92585 and G0453. 

We looked at the file and Medicare rules. Billed diagnosis codes M96.0, G95.9, and M54.2 are not listed as supporting medical necessity for the billed services. 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 testing services rendered on July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on May 5, 2021 by an out-of-network (OON) 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 an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 the home visit provided on May 5, 2021 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medication assisted treatment; methadone (G2067) rendered by the out-of-network (OON) provider from January 2, 2021, through January 30, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 the medication assisted treatment; methadone (G2067) rendered by the out-of-network (OON) provider from January 2, 2021, through January 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on March 25, 2021 by an out-of-network (OON) 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 an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 the eye exam provided on March 25, 2021 by an out-of-network (OON) provider.
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 this is necessary for you to regain maximum function. The Plan denied your request. The Plan says you are receiving appropriate care.

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 currently undergoing treatment at an acute care hospital (ACH) and are not intubated or ventilated. There is no evidence that you require services that are not currently available at the current facility. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on June 15, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you had a vision exam on February 20, 2021 but you needed to have a follow-up in June. You believe that because your first prescription was not correct, you should not have to pay for the second visit. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $40 copayment for medical eye exams. You have been asked to pay a $40 copayment for the medical eye exam. This copayment applies regardless of the reason for the medical eye exam. 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 medical eye exam you had on June 15, 2021.