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

We decided that the Plan does not have to pre-approve Tecentriq, carboplatin and etoposide.
You asked the Plan to pre-approve these drugs. You say that these are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness has not been demonstrated.
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 these drugs. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. The requested use of Tecentriq, carboplatin and etoposide is not FDA-approved for your diagnosis. FDA approval is for first-line treatment of extensive-stage small cell lung cancer in adults (in combination with carboplatin and etoposide). The use of these drugs is 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 your condition does not meet criteria for coverage of these drugs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq, carboplatin and etoposide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, molecular genetic screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 8, 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 the request for a home mechanical ventilator with low volume support settings that could be delivered by BiPAP with average volume-assured pressure support (AVAPS) 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's pulmonary diagnoses include chronic obstructive pulmonary disease (COPD), undefined pulmonary fibrosis and chronic hypoxic respiratory failure. The enrollee's significant co-morbidities include psoriasis, psoriatic arthritis, laryngeal
carcinoma, malignant melanoma, gastroesophageal reflux disease (GERD), Barrett's esophagus, AV malformations with gastrointestinal bleed (GIB), diabetes mellitus (DM) Atrial fibrillation (afib), coronary artery disease (CAD), status post coronary artery bypass grafting (CABG), and mitral valve repair. Minimal clinical data has been received from the clinical provider and the durable medical equipment company. There is no evidence submitted that the enrollee has been recently admitted to an inpatient service. Prior pulmonary evaluation including pulmonary function testing (PFT), arterial blood gas analysis (ABG), polysomnography (PSG), and overnight oximetry (ONO) are not available in the record for review. The review has determined that this patient has a history of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on July 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the facet joint radiofrequency ablation services. You say that these services
are medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan
says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that at least two medically reasonable and necessary
diagnostic MBBs must have been performed.
We looked at the file and Medicare rules. In this case, the record does not support that two MBBs have
previously been performed. Based on this information, we decided that Medicare rules for coverage of the facet
joint radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to
pre-approve the facet joint radiofrequency ablation (RFA) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a re-evaluation problem focused exam (D0170) provided on July 6, 2021.
You asked the Plan to pay for a re-evaluation problem focused exam. You say that this service should be covered under the Plan. The Plan denied your request. The Plan says the service at issue is not covered under your benefit plan per the EOC.
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 a re-evaluation problem focused exam (D0170) provided on July 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy sessions provided on June 21 to July 30, 2021.
You asked the Plan to waive the copayments for physical therapy sessions. You say that you cannot afford the charges for the services at issue. The Plan denied your request. The Plan says the correct copayments were applied.
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 each Medicare-covered physical therapy visit. You have been asked to pay less than or equal to a $40 copayment for each one of multiple physical therapy sessions. Physical therapy sessions fall within the "Outpatient rehabilitation services" benefit category. This
means that you have been asked to pay less than or equal to the full and 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 copayments for physical therapy sessions provided on June 21 to July 30, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no complex wound care needs, and any vent, PEG or intravenous medication needs can be safely provided in a skilled nursing facility. The LTACH will not provide any value-based care, and the enrollee can receive the appropriate treatment in a skilled nursing 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 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: Favorable

We decided that the Plan has to pay for out-of-area physician office visits on July 12 and July 23, 2021.
You asked the Plan to pay for out-of-area physician office visits. You say that the services at issue were urgently needed due to a diagnosis of cancer. The Plan denied your request. The Plan says that rules for payment for out-of-area care have not been met.
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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. You had testing done prior to leaving the service area and were informed that the tests were positive for cancer while you were still in Florida. The need for any sort of consultation regarding cancer would not have been foreseen. Enrollees are allowed to be outside of the Plan service area for up to six months at a time and retain coverage with the Plan. Upon learning of a new medical condition, the Plan cannot require or compel an enrollee to return to the service area to receive care that is time-sensitive (urgently needed). Given that this was a new diagnosis of cancer, we find that at least one evaluation by a Florida oncologist would be reasonable to ensure medical stability and to allow for the enrollee to decide whether to return home or leave the Plan and seek further treatment in Florida. Since the Plan did not attempt to obtain medical records from this initial consultation in Florida, we are not able to independently review whether the findings from that first exam would allow for the enrollee to reasonably obtain a follow-up care in the service area, or if this was required urgently. Without the records to review, we find that the second exam must also be considered urgently needed out-of-area care. Therefore, we decided that the Plan has to pay for out-of-area physician office visits on July 12 and July 23, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural injection services (62321).
You asked the Plan to pre-approve epidural injection services. You say that this request is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that the requested epidural injection services are subject to the criteria listed 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 epidural injection services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found that this 79-year-old gentleman has chronic neck and low back pain. He is status post a C4-C7 spinal fusion. His magnetic resonance imaging (MRI) scan shows some degree of cervical spinal stenosis and disc herniations higher in the neck. The patient has cervical spinal stenosis as well as herniated discs. The request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural injection services have been met. Therefore, we decided that the Plan does not have to pre-approve epidural injection services (62321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is responsible to obtain prior authorization for all of their patients, which should also cover for the medical treatments provided by the doctor. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 domiciliary or rest home visit (99336) provided on June 16, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on January 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested PT visits do not meet criteria.
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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is independent in a home exercise program. The enrollee's functional level does not require ongoing skilled PT. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on July 1, 2021.
You asked the Plan to pay for 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 CPT codes 0012M and 0013M are non-covered for CxBladder testing.
We looked at the file and Medicare rules. The CxBladder testing in this case was billed with code 0012M. This is not a covered code for CxBladder testing. 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 pay for the CxBladder testing provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 15, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing must be billed with the appropriate claim information. We looked at the file and Medicare rules. The pharmacogenomics testing in this was not billed with a Z-Code as required by A58324. 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 pay for the genetic testing provided on July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the billing of diagnosis related group (DRG) 184 for the inpatient services provided March 23, 2020, to March 29, 2020.
You asked the Plan to pay for the billing of DRG 184. You say that you disagree with the downgrade of DRG 184 to 185 and disagrees with the removal of encephalopathy The Plan denied your request. The Plan says the medical records show that inpatient hospital services have been reported with the incorrect DRG. The Plan disagrees that encephalopathy was a valid diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with G93.40 encephalopathy, unspecified. 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 the billing of DRG 184. Our reviewer says that the billing of DRG 184 is not supported by the medical records. Our physician reviewer found that the enrollee had rib fractures after a fall. She denied losing consciousness and was able to recall the whole event. She complained of pain only. No changes in mental status were noted. The provided records did not include sufficient documentation supporting the diagnosis of encephalopathy. Therefore the billing of DRG 184 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the billing of diagnosis related group (DRG) 184 for the inpatient services provided March 23, 2020, to March 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report rendered on May 11, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 electrocardiogram (EKG) interpretation and report rendered on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on May 4, 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 the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on May 4, 2021.