Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health skilled nursing services. You say that home health skilled nursing care is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health skilled nursing services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found you are a 67-year-old female with a history of diabetes mellitus and lymphedema. Based on the documentation provided, you do not have documented skilled nursing needs. Therefore, the requested home health skilled nursing services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services from September 7, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued psychiatric care is medically necessary. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for inpatient psychiatric care. They are compliant with treatment, stable, and are not a danger to self or others. The enrollee can be transferred to a lower level of care at this time.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. Our reviewer says that continuation of inpatient psychiatric care is not medically necessary in this case. Our physician reviewer found that based upon a review of the provided records, it is not expected that the enrollee will improve in a reasonable period of time beyond the dates in question as they were not showing any dangerousness to self or others, auditory or visual hallucinations, and they were without aggressive behaviors and not showing any acute threats of safety. The enrollee is cooperative and compliant with treatment. They have been found to be eating better and have been gaining weight. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The health plan's denial of continued inpatient psychiatric services appears appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services from September 7, 2021, onward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to LTACH.
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. The enrollee
is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit services with an out of network (OON) orthopedic surgeon.
You asked the Plan to pre-approve the OON office visit services. You say that the requested OON provider performed your operation and is very close to your home. You say that you are almost incapacitated and cannot be on the seat of a car for long drives. You say that you have not been able to sleep due to immense pain. You say that the participating orthopedic surgeons are too far from your home. The Plan denied your request. The Plan says there are in network orthopedic surgeons who can supply the care needed.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. The provider is a non-contract provider. We were able to confirm that the Plan has contract orthopedic surgeons located within reasonable distance and travel time from your home who can provide office visit services needed. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve office visit services with an out of network (OON) orthopedic surgeon
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract
specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted
technology (CPT code 88121) provided to the enrollee on April 13, 2021, by an out-of-network provider.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit
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, the service, 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
cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5
molecular probes, each specimen; using computer-assisted technology (CPT code 88121) 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 pay for the office visit (99213) rendered by the out-of-network (OON) provider on November 18, 2020.
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 (99213) rendered by the out-of-network (OON) provider on November 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra.
You asked the Plan to pre-approve Fasenra. 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 for the requested drug.
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 Fasenra. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee had shortness of breath and cough after workplace exposure to respiratory infection. The record indicates that the enrollee has a diagnosis of asthma. In this case, the Food and Drug Administration has stated that the requested drug is indicated for the add-on maintenance treatment of severe asthma in adults and children 12 years or older with an eosinophilic phenotype. The record does not indicate that the enrollee has asthma with an eosinophilic phenotype. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to pre-approve Fasenra
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT scan) of the chest (71250).
You asked the Plan to pre-approve a CT scan of the chest. You say that the service is medically necessary. The Plan denied your request. The Plan says the clinical information submitted does not established medical necessity.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT scan) of the chest (71250).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve muscle test, needle electromyography, each extremity, with related
paraspinal areas (95886) and nerve conduction test (95913).
You asked the Plan to pre-approve muscle test and nerve conduction test. You say that you have had bad
headaches with dizziness which makes your neck ache. The doctor would like to see you to verify the
symptoms The Plan denied your request. The Plan says that the request for a muscle test and a test for the
nerves is not medically needed at this time.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 muscle test and nerve conduction test.
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee is suspected of having a radiculopathy or possibly a form of
neuropathy. Both of these conditions are ones for which the LCD readily supports the provision of EMG/NCS
testing (EMG for radiculopathy and NCS for neuropathy). In such a setting this service would otherwise be
considered to be reasonable and necessary and therefore eligible for coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of muscle test and nerve conduction test have been met. Therefore, we decided
that the Plan has to pre-approve muscle test, needle electromyography, each extremity, with related paraspinal
areas (95886) and nerve conduction test (95913).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir (CPT code 54405-AS) provided to the enrollee on January 27, 2021, by a non-participating provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 54405-AS (1 Unit) remains not supported. The documentation submitted indicate that assistant surgical services were performed by a Licensed Surgical Assistant (LSA). Although skilled, Licensed Surgical Assistants are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines. Of note, per CMS/Medicare guidelines, the services of Surgical Technicians and RN First Assists (RNFA) are not eligible for separate reimbursement. Per Medicare Claims Processing Manual, "Only the AS modifier must be reported on the claim form when a NP or CNS bills assistant-at-surgery services." 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 pay for insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir (CPT code 54405-AS) provided to the enrollee on January 27, 2021, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a Group 2 support surface is covered when specific criteria are met. 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 services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records do not show that you have multiple stage two pressure ulcers located on the trunk or pelvis that have failed to improve over the past month while on a comprehensive ulcer treatment program. The records do not show that you have multiple stage three or four pressure ulcers on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. The criteria for coverage are not met and the services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nephrology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that going to different providers may be a risk when prescribing medications. The Plan denied your request. The Plan says the doctors in-network can provide the care you need.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve nephrology services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-area provider.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are in-network providers available in the service area.
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.
We looked at the file, and Medicare rules. Physical therapy services were requested to treat low back pain. The services do not appear to be urgent or emergent.
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 pre-approve physical therapy services to be provided by an out-of-area provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Gammagard solution (J1569).
You asked the Plan to pre-approve the Gammagard solution. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the Gammagard solution. Our reviewer says that the service is not medically necessary. Our physician reviewer found the requested use of Gammagard is not FDA-approved for the enrollee's diagnosis and its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). 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 Gammagard solution have not been met.
Therefore, we decided that the Plan does not have to pre-approve the Gammagard solution (J1569).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from June 1, 2020, through June 11, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 each Medicare-covered hospital stay. You have been asked to pay a $200 copayment for the Medicare-covered hospital stay provided. 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 inpatient hospital care provided from
June 1, 2020, through June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant controls.
You asked the Plan to pre-approve attendant controls. The Plan denied your request. The Plan says the item is non-covered.
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.
We looked at the file and the rules. If an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. 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 pre-approve attendant controls.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of the aorta (93979) provided on December 16, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a $116.35 copayment for the radiological diagnostic service provided. This is the
Plan's allowed amount for this service which is less than the applicable copayment. 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 duplex scan of the aorta (93979) provided on December 16, 2020.