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

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (CPT code 81455) provided to the enrollee on March 9, 2021.
You asked the Plan to pay for the laboratory services. You say that this is for targeted genomic sequence analysis panel for the enrollee with a diagnosis of cancer and this is used to help determine treatment. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the enrollee and will be denied automatically as not medically necessary and screening testing.
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 Medicare rules state this service is considered not medically necessary except when used to guide treatment decision making in individuals with non-small cell lung cancer. The test at issue in this appeal, the laboratory services, 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 targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (CPT code 81455) provided to the enrollee on March 9, 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 enrollee requires IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary according to Medicare 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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs.
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 the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula, nutritionally complete with intact nutrients (B4150) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the enteral formula. You say that you are 88 years old and have no teeth. You depend on liquid Ensure drink to supplement your daily diet for protein, much needed nutrition and to stay in good health and healthy weight. 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 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve enteral formula, nutritionally complete with intact nutrients (B4150) to be provided by an out-of-network (OON) provider.
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 enrollee will clearly benefit from acute rehab to
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the
criteria for an IRF are not met. The enrollee will not benefit from an intensive rehabilitation program, does not
have complex medical management needs, and does not require supervision by a rehabilitation physician.
Skilled therapies at home or in a nursing facility may be more appropriate.
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 the enrollee's 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement (CPT code 11043) provided to the enrollee
on April 13, 2021, by an out-of-network provider.
You asked the Plan to pay for the debridement. You say that the services provided were medically necessary and they were provided to the enrollee at the long-term care facility that the enrollee resides. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 debridement (CPT code 11043) provided to the enrollee on April 13, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the reporting of test results to a physician provided on April 5, 2021.

You asked the Plan to waive the copayment for the reporting of test results to a physician. You say that the services should be considered durable medical equipment and you should owe 20% coinsurance. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $45 copayment for specialist services. 

You received the reporting of test results to a physician on April 5, 2021. This is considered a specialist service. Therefore, you are responsible to pay the $45 copayment. 

You have been asked to pay a $45 copayment for the reporting of test results to a physician. The reporting of test results to a physician falls within the physician/practitioner services, including doctor's office visits 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 the reporting of test results to a physician provided on April 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 31, 2020.
You asked the Plan to pay for the laboratory services. You say that you attached the medical records required to process the claim. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (99205), extraction (41899), removal of torus mandibularis (21031), alveoloplasty with extractions (41874), and surgical placement of an implant body (21248).
You asked the Plan to pre-approve the dental services. You say that the extractions are medical in nature. You say that you were on medications that cause dry mouth. You also say that your teeth are now rotting and falling out. You also say that you are having issues with migraines and the upper side of your ear area. The Plan denied your request. The Plan says the extractions are to prepare the jaw for dentures. The Plan says that extractions to prepare the jaw for dentures are not covered. The Plan also says that the related services are not covered either.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (99205), extraction (41899), removal of torus mandibularis (21031), alveoloplasty with extractions (41874), and surgical placement of an implant body (21248).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on April 6, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you were told that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for X-rays provided in an outpatient hospital facility. You have been asked to pay a $100 copayment for an X-ray. An X-ray falls 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 an X-ray provided on April 6, 2021.
We note your complaint that you were told you would not owe a copayment. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that the enrollee uses PT as an ongoing
treatment for the enrollee's rare disease. The Plan denied your request. The Plan says additional PT is not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 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 additional requested therapy is not generally accepted as specific
and effective therapy for the enrollee's condition beyond what was approved by the health Plan. 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 authorized for four (4)
additional therapy sessions and should be able to transition to a home exercise program. 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 additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interim partial denture (D5820).
You asked the Plan to pre-approve the interim partial denture (D5820). You say that the bottom teeth are gone, and you need teeth in your mouth. You say that you need the partial denture to eat. The Plan denied your request. The Plan says the service is not a covered benefit.
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 pre-approve the interim partial denture (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller, harness, connection and seat cover.

You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration because the requested accessories are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested accessories.

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 wheelchair accessories. Our reviewer says that the documentation does not reveal that the member requires other types of proportional input devices or non-proportional input devices. The member does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The member's strength in the upper extremities indicates that the patient can control any power options through their own individual switches. Our physician reviewer found the K0108 foot plate bracket is miscoded as this item has a specific HCPCS code. The replacement seat cover E2619 exceeds the patient's medical need and is 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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller, harness, connection and seat cover.
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 IRF care. The Plan denied your request.
The Plan says rules for IRF care have 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 that you were admitted for a stroke and chronic sinusitis. 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CAR-T therapy with Yescarta.
You asked the Plan to pre-approve CAR-T therapy with Yescarta. You say that the records provided support
that the requested drug is appropriate and medically necessary for the enrollee. The Plan denied your request.
The Plan says the records indicate that the enrollee's lymphoma is responding the current treatment.
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 CAR-T therapy with Yescarta. Our
reviewer says that the criteria for coverage have not been met.
Our physician reviewer found CAR-T therapy with Yescarta is not FDA approved for marginal zone
lymphoma. The enrollee does not have relapsed or refractory disease. Recent positron emission tomography
(PET) scan services showed improvement. The documentation does not support that the CAR-T therapy with
Yescarta is 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 CAR-T therapy with Yescarta have not been met. Therefore, we decided that
the Plan does not have to pre-approve CAR-T therapy with Yescarta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nephrology visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve nephrology visits with an out-of-network provider. You say that the nephrologist you are requesting was very helpful in coming up with a plan for you. The Plan denied your request. The Plan says your nephrology care can be provided within the 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 nephrology visits to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis for the enrollee.

You asked the Plan to pre-approve Hymovis. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that the member has not tried and failed Monovisc.

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 Hymovis. Our reviewer says that
Hymovis is not medically reasonable and necessary for the enrollee. The case file does not contain
documentation of trial and failure of Monovisc. The documentation does not support that Monovisc would
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician
reviewer found that the enrollee's condition does not meet step therapy criteria for Hymovis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hymovis for the enrollee.