Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased February 2, 2020 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you have went to this provider before but you did not know that they were out of the network. You didn't ask for these tests and at 82 didn't know what they were for. The Plan denied your request. The Plan says hearing aids must be purchased through a provider that is a part of the vendor network to be covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only purchased through an in-network provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased February 2, 2020 from an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Logisticare mileage.
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary to attend medical appointments. The Plan denied your request. The Plan says the service is a covered benefit but the request exceeds the mileage limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles one-way per trip. We looked at your request, the records in the case file, and the rules. The requested trip is longer than 50 miles one-way. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional Logisticare mileage.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided on September 30, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the clinical documentation supports that the admission was warranted. You say that the treating physician exercised their expert opinion in electing to admit this enrollee out of concern that the symptoms were attributed to an escalating clinical condition.The Plan denied your request. The Plan says that the provider is non-contracted and the out of network care was not authorized.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on September 30, 2019 with fever, chills, abdominal pain, vomiting and lethargy. On evaluation her temperature was 100.8 and she had a tachycardia to 114. Labs revealed an abnormal UA. CXR demonstrated bilateral infiltrates. CT of the abdomen and pelvis revealed evidence for an LLL pneumonia and bilateral perinephric stranding c/w pyelonephritis. She was treated with IV fluids, and IV Zosyn and Vancomycin. She was admitted with a diagnosis of sepsis secondary to acute cystitis and pneumonia. She required continued treatment and was transferred to a higher level of care. The record did show that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care)would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan hasto pay forthe acute inpatient hospital care provided on September 30, 2019. 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 pre-approve a T5 kyphoplasty.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not covered by Medicare for this condition.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the medical records do not show that the fracture is less than six weeks old, or that you have
been evaluated by at least three doctors.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve a T5 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code A4550 provided on April 16, 2019.
You asked the Plan to pay for CPT code A4550. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code A4550 remains unsupported as it is an unbundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare specifically says that CPT code A4550 is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of CPT code A4550 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code A4550 provided on April 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health admission.You asked the Plan to pre-approve inpatient behavioral health admission. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 inpatient behavioral health admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others. They were without agitation or aggression and without perceptual disturbance including auditory or visual hallucinations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health admission have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the enrollee does not have any identifiable skilled nursing service needs. While she has skilled therapy needs, she does not need therapy on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection, nivolumab, 1 mg (CPT Code J9299), for the
enrollee.
You asked the Plan to pre-approve the Part B drug. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says the information provided by the doctor does not meet
Medicare's guideline.
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 Part B drug. Our physician reviewer
found the requested use of Opdivo FDA-approved is not for the enrollee's diagnosis. The use is not supported
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Is
the use listed as not indicated, not supported or not recommended in any of the compendia? No.
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 Part B drug have not been met. Therefore, we decided that the Plan does not
have to pre-approve injection, nivolumab, 1 mg (CPT Code J9299), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on February 13, 2020. You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is bundled into the payment for another procedure. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 office visit. Our reviewer says that CPT code 99213 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation is difficult to read and only included one office visit for this date of service and 3 claim forms. This is considered unbundling. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foran office visit (99213) and drug test (80305) provided on February 24, 2020.You asked the Plan to pay forthe office visit and drug test. You say that you would like reconsideration because this claim has been denied in error.The Plan denied your request. The Plan says that the provider is not eligible to perform the services billed.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has not shown that the provider at issue was precluded from Medicare payment for the dates of service at issue. The Plan has provided screenshots of a list, but it is unclear from the screenshot if it is the Medicare Preclusion list (there are no headers and the screenshot itself does not have an indication as to where this information came from). Without this information, we are unable to verify that the provider at issue was precluded from Medicare payment for the dates of service at issue.Therefore, we decided that the Plan has to pay foran office visit (99213) and drug test (80305) provided on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the criteria for admission
have been met. The Plan denied your request. The Plan says outpatient therapy, medication management, and
case management at an alternative level of care would be more appropriate than an inpatient admission.
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 inpatient psychiatric services. Our
reviewer says that inpatient psychiatric services are not medically necessary. Our physician reviewer found the
enrollee has shown no mood instability, nor any thoughts of harming himself or others. He did not have any
delusions or hallucinations and did not have any auditory or visual hallucinations. The enrollee was cooperative
with care and actively involved in his treatment. Community-based outpatient treatment is appropriate 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 the inpatient psychiatric services have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveparavertebral facet joint injections (64493).You asked the Plan to pre-approveparavertebral facet jointinjections. You say that this is medically necessary.The Plan denied your request. The Plan says the requested procedure is not indicated at this time.The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when pain isnot associated with radiculopathyand when dual medial branch blocks (MBBs) provide > 80% relief of the primary or index pain.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 paravertebral facet joint injections. Our reviewer says that the criteria for coverage of facet joint injections have not been met. Our physician reviewer found the records show that the enrollee has radicular pain and only achieved 40% pain relief from the first diagnostic set of MBBs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approveparavertebral facet joint injections (64493).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home injectable hormone therapy billed with CPT code
S9560.
You asked the Plan to pre-approve CPT code S9560. You say that the enrollee needs the requested services and
is pregnant with a singleton pregnancy. The Plan denied your request. The Plan says Medicare and the Plan do
not cover the administrative code requested.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules say that HCPCS/CPT codes with a
status indicator of I are not recognized by Medicare and will not be paid. Medicare uses another code for
reporting of, and payment for, these services.
In this case, the CPT code in dispute has a status indicator of "I" and will not be paid by Medicare. This service
should be reported with a code that is recognized by Medicare. Therefore, we decided that the Plan does not
have to pre-approve home injectable hormone therapy billed with CPT code S9560.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 above. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. You are reportedly walking hundreds of feet. Your care needs can be met at a lower level of 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health, and home physical therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee meets the criteria for this procedure and care in an IRF is medically necessary.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needed care cold be provided in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 the enrollee was admitted to the hospital on June 23, 2020 with weakness and hyponatremia. His past medical history is notable for muscular dystrophy, COPD, heart disease, and diabetes. The enrollee's vital signs are normal. His weakness makes getting out of bed difficult. The enrollee's glucose levels are modestly elevated and the sodium level has improved. It is noted that the enrollee is weaker that his prior level of function. The complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is relatively stable and does not have complex medical issues that require acute rehabilitation nursing care or monitoring by an inpatient rehabilitation physician three times per week. While the enrollee may benefit from continuing physical therapy and occupational therapy, there isno evidence of a need for an intensive therapy program with therapy for 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.