Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on January 9, 2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you have never paid for your ostomy supplies and you do not think you should pay anything for them. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for prosthetic devices and medical supplies.
You have been asked to pay $37.28 which is 20% of the allowed amount for the ostomy supplies. The allowed amount is $186.40. (186.40 x 20% = $37.28). The ostomy supplies fall within the "Prosthetic devices and related 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 the ostomy supplies provided on January 9, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay for17 additional hours of observation services provided to the enrollee on December 13, 2019.You asked the Planto pay forthe additional observation hours. You say that this should be paid for.The Plandenied your request. The Plansaysthe additional observation services over the Medicare allowable were 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 pay for the additional observation hours. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was stable for discharge on 12/12/2019. Family/social issues prevented the enrollee from being discharged. Such issues are not an issue of medically necessity and do not warrant payment for medical services. The additional day of observation services was 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 the additional observation hours have not been met.Therefore, we decided that the Plandoes not haveto pay for17 additional hours of observation services provided to the enrollee on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the formation of a direct or tubed pedicle (15574) provided on October 15, 2019. You asked the Plan to pay for the formation of a direct or tubed pedicle. You say that the documentation shows this procedure. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 15574 is formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet. 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 formation of a direct or tubed pedicle. Our reviewer says that this code is not supported. Our physician reviewer found this procedure is not clearly documented in the submitted documentation, therefore, this code cannot be verified. 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 formation of a direct or tubed pedicle have not been met. Therefore, we decided that the Plan does not have to pay for the formation of a direct or tubed pedicle (15574) provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that the foot inserts are necessary for your foot deformity.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on February 18, 2020.You asked the Plan to waive the copayment forthe ambulance transport. You say that you were told that you would not be billed a copayment for the ambulance ride. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 forthe ambulance transport provided on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cabergoline for the enrollee.You asked the Plan to pre-approve this drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Cabergoline for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that you recently broke your leg and are experiencing severe pain. You say that this is making it hard to maneuver around your home. You say that physical and occupational therapy would be beneficial and help you gain the strength and independence needed to be at home.The Plan denied your request. The Plan says the enrollee does not show a need for complicated medical care. The Plan says that the care needed by the enrollee is considered custodial.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 todetermine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care, a need for IV antibiotics, or other skilled nursing needs. The enrollee's functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment only in a SNF. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter, this enrollee does not require the necessary services on 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 6, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not contact the plan for authorization of these services.
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 rendering 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. 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 lab services provided to the enrollee on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that intensive therapy is needed to maximize function and independence. The Plan denied your request. The Plan says the enrollee does not have complex medical condition which require an intensive team for care.
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 physician reviewer found that the enrollee is at contact guard assist for sitting up, and minimal assist for standing up, transfers to toilet, and sitting down. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee will be limited by her weight-bearing status. 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: Favorable

We decided that the Plan has to pre-approve admission to a long-term acute care hospital (LTACH).You asked the Plan to pre-approve the LTACH admission. You say that it is felt that it would be best for this enrollee to receive their ongoing care in the LTACH setting.The Plan denied your request. The Plan says that there is no need for LTACH care since the current hospital can meet all needs.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 the LTACH admission. Our reviewer says that the requested admission to the LTACH facility is found to be medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 72-year-old man with multiple medical problems, including acute hypoxemic respiratory failure, acute renal failure, metabolic acidosis, NSTEMI, cardiogenic shock, acute systolic congestive heart failure, and diabetes. A tracheostomy and PEG tube have been placed. In an appeal letter dated 6/3/20, it is documented that the enrollee is hemodynamically stable, in critical illness recovery stage, and safe for transfer. It is noted that the hospital is in severe need of ICU beds secondary to an increase of positive Covid-19 hospital admissions in their geographical area. CMS has published a statement explicitly stating that "During the COVID-19 pandemic, long-term acute-care hospitals can now accept any acute-care hospital patients." It has been determined that the enrollee in this case is in need of continued acute care. As such, the requested LTACH services are medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the LTACH admission have been met.Therefore, we decided that the Plan has to pre-approve admission to a long-term acute care hospital (LTACH).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvea sacroiliac (SI) joint injection.You asked the Plan to pre-approvethese services. You say that this is the only treatment that helps the enrollee's pain.The Plan denied your request. The Plan says that the services are not medically necessary.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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic back pain and a lumbar vertebral body fracture. She has pain in her hips and tenderness over the SI joint. She is doing a home exercise program and has had trigger point injections. A therapeutic SI joint injection is the standard of care and is reasonable and 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 these services have been met.Therefore, we decided that the Plan has to pre-approvea sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is going to require prolonged acute level care which would be best provided in the LTACH setting. The Plan denied your request. The Plan says the enrollee's conditions are such that treatment in a lower level of care is appropriate.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH for respiratory failure in the setting of metastatic lung cancer. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. The enrollee is non-compliant with PAP therapy. The oncologist has recommended ongoing palliative care. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zilretta injection (Triamcinolone Acetonide code
J3304).
You asked the Plan to pre-approve the Zilretta injection. You say that Zilretta is medically necessary for the
enrollee. The Plan denied your request. The Plan says the request for repeat injections of Zilretta is not eligible
for coverage by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Zilretta injection. Our reviewer says
that the Zilretta injection does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee
has received multiple prior Zilretta injections to the right knee with reported benefit. Our reviewer found that
the current Food and Drug Administrations (FDA) indications state that Zilretta injections are not indicated for
repeat administration as the efficacy and safety has not been demonstrated. Current evidence based medical
literature notes recent study findings suggest a repeat Zilretta injection may be efficacious without deleterious
effects, but further investigation with longer-term and/or placebo-controlled studies was recommended. Our
physician reviewer also found that the documentation does not support that Zilretta is medically reasonable and
necessary or safe and effective for treatment of this enrollee's medical condition 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 the Zilretta injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Zilretta injection (Triamcinolone Acetonide code J3304).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.You asked the Planto pre-approve the Keytruda injections. You say that it is felt that this should be approved.The Plan denied your request. The Plan says the enrollee has had disease progression on this treatment so it is not appropriate to use at this time.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Keytruda injections. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of melanoma with prior treatment with Keytruda with progression of disease. Tafiniar and Mekinist were recently discontinued due to side effects. In this case, re-initiating treatment with a drug on which the enrollee has already had disease progression is not considered reasonable and 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 Keytruda injections have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for LTACH care.The Plan denied your request. The Plan says the enrollee's needs could be met at the current hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19 complicated by renal failure and encephalopathy. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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.