Persius/hicric huggingface dataset:
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that this request exceeds the enrollee's needs.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for encephalopathy and a urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingles vaccine provided September 2, 2020, to
December 3, 2020.
You asked the Plan to pay for the Shingles vaccine. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says these vaccinations are not covered under
the medical benefit of your Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided September
2, 2020, to December 3, 2020.
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 IRF care is medically necessary. 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 the patient was admitted for lumbar spine surgery. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the enrollee is a 60-year-old female with a
past medical history of multiple sclerosis who presented to the acute hospital on May 14, 2021, with seizure
activity and altered mental status. While this patient does require skilled therapy services, there is no
documentation that the patient requires skilled nursing services. In addition, daily skilled services are not
required. Finally, this patient does not require the services on an inpatient basis, only in a skilled nursing
facility setting. Services in a long-term care facility on a part time basis appear 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 SNF care 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PET scan.
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the records do not indicate a concern for FTD.
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 PET scan. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare only covers a PET CT to differentiate between Alzheimer's disease (AD)and Frontotemporal Dementia (FTD). The member in this case is not suspected of having FTD. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on January 25, 2021.
You asked the Plan to pay for the dental service. You say that you chose this plan because you were told by the plan representative that crowns would be covered. The Plan denied your request. The Plan says crown is not listed as a covered service.
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 the crown (D2740) provided on January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0429, A0425) provided on November 24, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that, because the ambulance order was put forth by a doctor associated with the Plan and you were not told ahead of time that you would be responsible for the payment, you should not be responsible for this claim. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $191 for these services. This means that you have been asked to pay less than or equal to 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 ambulance services (A0429, A0425) provided on November 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed Zoledronic acid, and does not have a history of osteoporotic fracture.
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 Prolia. Our physician reviewer found that the enrollee has age-related osteoporosis. She has tried and failed Fosamax due to gastroesophageal reflux symptoms. The Plan requires a trial of zoledronic acid or have a history of osteoporotic fracture before they will approve the requested drug. The enrollee has not tried and failed the required drug and there is no reported history of an osteoporotic fracture. There is no indication that the plan's required drug would likely be less effective or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.
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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with spinal stenosis. The Vertiflex device is experimental. More research is needed to show safety and efficacy. The requested Vertiflex device is not medically necessary at this time.
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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health treatment.

You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information submitted does not establish medical necessity.

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 the treatment. Our reviewer says that the requested treatment is not medically reasonable or necessary. Our physician reviewer found active treatment is not taking place. There is no individualized treatment plan evident. The enrollee could be treated in a lesser restrictive setting. There is no evidence of suicidal/homicidal ideation, auditory/visual hallucinations, or delusions. There is no evidence of aggressive behaviors. The enrollee is cooperative and compliant and showing no acute threats to safety.

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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography, soft tissue neck (70491) low osmolar contrast material, 300-399 mg/ml iodine concentration (Q9967) provided January 9, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that the focus of this appeal is primarily on billing, but you left the provider for a good reason which you documented to their patient services. The Plan denied your request. The Plan says this claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 $110 copayment for each radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility and 20% coinsurance for each Medicare covered medical supply. You have been asked to pay $110.02 ($110 copayment and $0.02 coinsurance) for the diagnostic service. The diagnostic service 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 computed tomography, soft tissue neck (70491) low osmolar contrast material, 300-399 mg/ml iodine concentration (Q9967) provided January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services rendered on December 3, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital facility.
Review of the file shows that you received outpatient surgical services on December 3, 2020. You have been asked to pay a $260 copayment for these services. These services fall within the Medicare-covered surgery or other services provided to you at an outpatient hospital facility 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 surgical services rendered on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cisplatin, pembrolizumab, and capecitabine chemotherapy.

You asked the Plan to pre-approve the requested chemotherapy regimen. You say that it is felt that this treatment would be beneficial. The Plan denied your request. The Plan says there is not support for this treatment regimen for gastric cancer.

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 requested chemotherapy regimen. Our reviewer says that the requested treatment regimen is not supported as being medically reasonable and necessary. Our physician reviewer found the enrollee has stage IV gastric cancer. The requested regimen is not supported by Medicare-approved cancer compendia. No literature was submitted in support of the requested regimen. The elements of the coverage rules 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 requested chemotherapy regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve cisplatin, pembrolizumab, and capecitabine chemotherapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a single-photon emission computerized tomography (SPECT) scan (78452) and a cardiovascular stress test (93015) performed on September 16, 2019.

You asked the Plan to waive the coinsurance for a SPECT scan and a cardiovascular stress test. You say that that you have been informed that the claims in question had been paid in full by the Plan and that you owe no balance. The Plan denied your request. The Plan says the correct coinsurance was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered non-radiological diagnostic services as well as for each Medicare-covered radiological diagnostic service, not including X-rays.

You have been asked to pay $93.49, or 20% of the combined Medicare-allowed amount of $467.47, for a SPECT scan and a cardiovascular stress test. A SPECT scan and a cardiovascular stress test 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 coinsurance for a single-photon emission computerized tomography (SPECT) scan (78452) and a cardiovascular stress test (93015) performed on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for supply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply equals 1 unit of service (CPT code K0553-KX-CG-KF) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554-4-NU-KX-CG-KF) provided to the enrollee on November 30, 2020.
You asked the Plan to pay for the items. You say that the claim should be paid. The Plan denied your request. The Plan says that the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.
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 items. Our physician reviewer found the above coverage rules states that if there is medical necessity for the prescribed devices, then the device is covered. There is no mention in the above coverage rules for the number of injections (3) or frequency of blood glucose (BG) checks being done. This enrollee has diabetes mellitus and has suboptimal control on bid insulin shots. The enhanced ability to check with the libre would help the enrollee adjust, diet, and perhaps doses of insulin; hence, using this Food and Drug Administration (FDA) approved device in this clinical setting meets the listed criteria given above. 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 items have been met. Therefore, we decided that the Plan has to pay for supply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply equals 1 unit of service (CPT code K0553-KX-CG-KF) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554-4-NU-KX-CG-KF) provided to the enrollee on November 30, 2020.
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.