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

 We decided that the Plan does not have to pay for pharmacogenomics panels for DNA assay (CPT code(s): 81479 x9, 81408 x2, 81406, 81401 x2,81400, 81355, 81350, 81335, 81328, 81291, 81283, 81256, 81241, 81240, 81232, 81231, 81230, 81227, 81226, and 81225) provided to the enrollee on June 24, 2021.  
You asked the Plan to pay for the laboratory services. You say 
that this service was denied as experimental in error. The Plan denied your request. The Plan says the medical necessity coverage criteria are not met since the selection of the medications in question are not derived from clinical factors/necessity. The Plan states the enrollee is not taking Warfarin treatment and is not a participant in a controlled clinical study for evidence development. The Plan states the testing also is not covered as billed. 
 
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 pay for the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no indication for this testing such as current symptoms or signs of a current disease, and there was no treatment decision that would be significantly influenced by the results of this test to bypass standard testing and treatment methods. Many of the tests ordered were related to medications that were not planned on being prescribed or were not current prescribed. Therefore, without sufficient justification made for this request, the pharmacogenomics panels will be considered not medically 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenomics panels for DNA assay (CPT code(s): 81479 x9, 81408 x2, 81406, 81401 x2,81400, 81355, 81350, 81335, 81328, 81291, 81283, 81256, 81241, 81240, 81232, 81231, 81230, 81227, 81226, and 81225) provided to the enrollee on June 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services (36228, 36224, 36223, 76377) provided on January 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the surgery services. You say that you were advised by a representative of the Plan that prior authorization would not be required for these services. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited circumstances. The services at issue were not urgent/emergent or pre-approved. Therefore, payment is denied.  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 surgery services (36228, 36224, 36223, 76377) provided on January 19, 2021 by an out-of-network (OON) provider.   Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says based on the information available, the enrollee does not meet the criteria for this admission.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 power operated wheelchair with multiple power options and related accessories.  

You asked the Plan to pre-approve a group 2 power operated wheelchair with multiple power options and related accessories. You say that this is medically reasonable and necessary. 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 a power operated vehicle is 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 a group 2 power operated wheelchair with multiple power options and related accessories. Our reviewer says that the criteria for coverage of the power operated vehicle have not been met. Our physician reviewer found that the documentation indicates the patient has a mobility deficit that impairs MRADLs in the home and is not ameliorated by a walker, cane, manual wheelchair due to fatigue, pain, and weakness. She also has the cognitive ability to use a power wheelchair safely. However, the home evaluation is unsigned by the patient and it is not clear from the document on September 28 that the wheelchair can fit in the bathroom which is the narrowest interior doorway width. While the patient may be able to safely maneuver the equipment, the record is vague on whether the requested wheelchair will significantly improve MRADL participation in the home as it can only be used downstairs and the bathroom doorway is noted to be 30 inches. The home evaluation document is not explicitly clear that the home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is requested. As a result, the criteria for coverage of a group 2 power operated wheelchair with accessories have not been met.  

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 group 2 power operated wheelchair with multiple power options and related accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated wheelchair with multiple power options and related accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing services provided on August 3, 2021.

You asked the Plan to pay for the services provided. You say that the test informs clinicians about which 
medications may require adjustments. The Plan denied your request. The Plan says the test has not been shown 
to be useful.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications. 

We looked at the file, and Medicare rules. The provided pharmacogenetic testing was reportedly ordered to 
make decisions about the patient's medications. Medications should be provided based on the presence of a 
diagnosis and should be adjusted based on a patient's response to the medication. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the GeneSight testing services provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a bevacizumab injection for the eye provided on July 13, 2021.  

You asked the Plan to waive the copayment for the injection. You say that you were not aware of the increased copayment. The Plan denied your request. The Plan says you have been charged 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 $300 copayment for surgical services provided at an outpatient hospital.  

 You have been asked to pay a $300 copayment for the injection. The injection falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for a bevacizumab injection for the eye provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 gene (prothrombin coagulation factor II) and F5
gene (coagulation factor V) testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not considered clinically efficacious.
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 the enrollee is over 50 and has no family history of venous thromboembolism (VTE) or unusual site.
Despite having recurrent VTE, the enrollee is unlikely to carry the gene, and finding out if they have one is
unlikely to change management. Both VTEs were provoked and weight loss is significant for underlying
malignancy or other underlying disorder that may make them hypercoagulable. The service is not reasonable or
medically 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 testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve F2 gene (prothrombin coagulation factor II) and F5 gene (coagulation factor V) testing.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable and is gradually improving and should only require short-term additional acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.  

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there must be a trial and failure of the preferred products.  

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has not tried and failed the plan's preferred brand products and does not indicate any contraindication to doing so. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.   

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Pembrolizumab for the enrollee.  

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that medical studies haven't proven that the requested drug is helpful when you've already tried Keytruda (anti-PDL-1 therapy) and didn't have a positive response.  

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 medically reasonable and necessary. Our physician reviewer found the positron emission tomography (PET) scan shows largely stable disease, so the requested drug is medically reasonable and necessary. The enrollee has been tolerating the drug, and it has kept the disease largely stable.  

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 been met. Therefore, we decided that the Plan has to pre-approve Pembrolizumab for the enrollee.   

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on July 10, 2021. 

 You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on April 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration because a referral is not needed for Indian Health Services. The Plan denied your request. The Plan says this service was not urgent, emergent or approved in advance.

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 annual wellness visit (G0439) provided on April 28, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), adjust complete denture - mandibular (D5411), and reline complete mandibular denture (direct) (D5731) provided July 22, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the limited oral exam and lower denture adjustment and reline. You say that you weren't able to get into a network dentist and the services were necessary due to pain. The Plan denied your request. The Plan says these services are not covered when provided OON. The Plan additionally states that you were told prior to the services that the OON services would not be 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. The Plan covers the limited oral exam and lower denture adjustment and reline when the services are provided by a network provider.

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam and lower denture adjustment and reline have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), adjust complete denture - mandibular (D5411), and reline complete mandibular denture (direct) (D5731) provided July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test (78452) provided on November 
18, 2020.

You asked the Plan to waive the copayment for the stress test. You say that the services should be covered as 
you already partially paid for these services in 2020. The Plan denied your request. The Plan says the costsharing 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 $200 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $200 copayment for a stress test. Stress tests 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 copayment 
for a stress test (78452) provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the separate inpatient admission provided from August 8, 2021, to August 11, 2021.

You asked the Plan to pay for the separate inpatient admission. You say that you strongly believe the services provided during admission should be paid as a separate inpatient admission. The Plan denied your request. The Plan says that the symptoms and findings for this current hospitalization are consistent with a result of the prior hospitalization from June 21, 2021, to July 27, 2021. The Plan also says that this hospitalization will be linked to the prior hospitalization and the request for a separate admission is denied.

The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically necessary, and if the readmission did not result from a premature discharge from the same hospital. 

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 separate inpatient admission. Our physician reviewer found the documentation supports that the readmission was medically reasonable and necessary for the enrollee in this case. Our reviewer also found that the documentation does not support that the readmission resulted from a premature discharge from the same hospital. 

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 separate inpatient admission have been met. Therefore, we decided that the Plan has to pay for the separate inpatient admission provided from August 8, 2021, to August 11, 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.