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

We decided that the Plan does not have to pre-approve routine transportation with a stretcher accessible vehicle for the enrollee.You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that this is not covered by the plan.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 does not cover routine transportation with stretcher accessibility. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve routine transportation with a stretcher accessible vehicle for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by out of network provider.You asked the Plan to pay for these services. You say that you were unaware that provider was out-of-network.The Plan denied your request. The Plan says the services were 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower seat lift chair.You asked the Plan to pre-approvethe power seat lift chair. You say that the records should support the necessity of the item in disputeThe Plan denied your request. The Plan says the request for a  power seat lift chair is not medically necessary.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above 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 the power seat lift chair. Our reviewer says that this enrollee does not meet the criteria for power seat lift chair.Our physician reviewer found the documentation does not reveal that the enrollee has severe arthritis of the hip; and/or a neuromuscular disease. The records do not show that a seat lift is included in the physician's course of treatment. The seat lift is not likely to affect improvement in the enrollee's condition.  The records do not show that the enrollee is completely incapable of standing from a chair in the home. The records do show that the patient is able to ambulate.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 power seat lift chair have not been met.Therefore, we decided that the Plan does not have to pre-approvepower seat lift chair.
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pre-approveSimponi Aria (golimumab) injections.You asked the Planto pre-approvethe Simponi Aria injections. You say that the enrollee has had positive results using this drug.The Plandenied your request. The Plansaysthatthere is no evidence that she is taking methotrexate with Simponi Aria. The Plan did not review its original denial rationale as it missed the timeframe.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 Simponi Aria injections. Our reviewer says that the documentation supports that this drug is medically reasonable and necessary. Our physician reviewer found the patient has documented rheumatoid arthritis and she has failed single DMARD treatment. She is taking methotrexate 10 mg each week concomitantly with the Simponi Aria as documented in the provided medical records of 01/06/2020 and 12/10/2019.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 Simponi Aria injections have been met.Therefore, we decided that the Planhas to pre-approveSimponi Aria (golimumab) injections.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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-approvepercutaneous vertebral augmentation (22513).You asked the Plan to pre-approvepercutaneous vertebral augmentation. You say that this is medically necessary.The Plan denied your request. The Plan says the LCD criteria have not been met.The Plan follows Medicare rules. Medicare rules say that in order for percutaneous vertebral augmentation to be covered, the enrollee's pain must be refractory to conservative measures employed for reasonable periods of time. 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 percutaneous vertebral augmentation. Our reviewer says that percutaneous vertebral augmentation is not reasonable and necessary at this time. Our physician reviewer found there is no documentation of adequate conservative measures tried for the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentation have not been met.Therefore, we decided that the Plan does not have to pre-approvepercutaneous vertebral augmentation (22513).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care beyond January 15, 2020.You asked the Planto pre-approvethe continued SNF care. You say that your physical therapist feels that you are not ready to return home. You need continued therapy.The Plandenied your request. The Plansaysyou do not require the level of care and can be treated with less than daily therapy in the home health/outpatient setting.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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 68 year old male with pancreatic cancer who recently had a Whipple procedure and colostomy with protein calorie malnutrition with feeding tube. From a nursing perspective, the beneficiary received oral medications and enteral nutrition. The beneficiary had stable vital signs. He completed a course of IV antibiotics for bacteremia. Regarding rehabilitation services, the beneficiary received PT, ST and OT in the SNF. By the dates in question, the beneficiary was at supervision to independent level for functional mobility including gait to 200 feet with a rolling walker. The beneficiary required varying assist with ADLs.
There are no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs. However, these do not require daily skilled nursing care. This beneficiary 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 the continued SNF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care beyond January 15, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 1, 2019 to September 19, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider"  from July 1, 2019 to September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRetacrit.You asked the Plan to pre-approveRetacrit. You say that low hemoglobin levels need to be treated.The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Retacrit. Our physician reviewer found that you were diagnosed with iron deficiency anemia. This diagnosis is not FDA supported for this medication. The requested use of the drug is not supported by Medicare-approved compendia. Without the support of the literature, medical necessity cannot be determined. Therefore, the requested service is not considered medically 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approveRetacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 13, 2019 to November 1, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 13, 2019 to November 1, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvea lumbar epidural steroid injection (ESI).You asked the Planto pre-approvethe lumbar ESI. You say that this is a necessary treatment.The Plandenied your request. The Plansaysthatthere is no documentation of four weeks of conservative care.The Plan follows Medicare rules. Medicare rules say that ESIs are covered for discogenic pain/neurogenic claudication when there are imaging abnormalities including central spinal stenosis. 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 lumbar ESI. Our reviewer says that the requested ESI is considered reasonable and necessary in this case. Our physician reviewer found the patient is s/p lumbar laminectomy and has central spinal stenosis. His medications are not providing adequate relief. He is doing a Home exercise program. He meets the criteria of the LCD and the requested procedure is medically 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 lumbar ESI have been met.Therefore, we decided that the Planhas to pre-approvea lumbar epidural steroid injection (ESI).If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe psychiatric evaluation provided on August 29, 2019.You asked the Plan to waive the copayment forthe psychiatric evaluation. You say that you were informed the copayment would be $10. You say that you would not have made the appointment if you knew the cost was $40 per visit.The Plan denied your request. The Plan says the copayment 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 $40 copayment per provider per day for in-network outpatient mental healthcare from other Medicare-eligible providers.You have been asked to pay a $40 copayment for the psychiatric evaluation. The psychiatric evaluation falls within the "Outpatient mental health care" benefit category. The records show that the provider is a psychologist. This means that you havebeen 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 psychiatric evaluation provided on August 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH would be best for the enrollee's ongoing care.The Plan denied your request. The Plan says long term acute care can be equally provided in any 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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory therapy with oxygen supplementation and intermittent BiPAP support, surveillance laboratory studies, determined transfusions, fluid balance with intravenous diuretic, telemetry monitoring, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requestedLTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forcardiology services provided to"the beneficiary" on May 26, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe billed diagnosis code may only be used as a first-listed or primary diagnosis position.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 find that CPT code 93010 is not supported in the medical record. Specifically, this CPTcode was billed with diagnosis code Z18.10 as the fourth diagnosis code. This code is meant to be used as a first-listed, primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forcardiology services provided to "the beneficiary" on May 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessaryThe Plandenied your request. The Plansaysthis is not medically necessary.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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the hospital outpatient visit or the specialist office visit provided on August 19, 2019.You asked the Plan to waive the cost share forthe hospital outpatient visit and the specialist office visit. You say that you have never paid a facility fee before and have only ever been charged for office visits.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. Your contract with the Plan says that there is a $300 deductiblethat applies towards Medicare-covered in-network outpatient facility visits and a $35 copayment foreach Medicare-covered visit with an in-network specialist. The hospital outpatient visityou asked the Plan to waive the cost share for falls within the"Outpatient hospital services" benefit category. The Plan has followed Medicarerules by clearly disclosing in the contract that there is a $300 deductiblethat applies towards in-network outpatient hospital visits. The allowed amount for the hospital outpatient visit is $116.75. Therefore, $116.75 was applied towards your $300 deductible.You have also been asked to pay a $35 copayment for the specialistoffice visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed separately for these services.
This cost sharing is a contractual obligation that had not been met at the time the hospital outpatient visit and the specialist office visit werereceived on August 19, 2019.Therefore, we decided that the Plan does not haveto waive the cost share forthehospital outpatient visit or thespecialist office visit provided on August 19, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 10, 2020.You asked the Plan to pre-approve the continued SNF care. You say that you feel that you need more therapy in the SNF.The Plan denied your request. The Plan says you no longer require daily skilled services.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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 75 year old female who underwent total hip replacement and was admitted to SNF on 12/16/2019. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at supervision to modified independent level for functional mobility including gait to 70 feet with a rolling walker. The beneficiary required varying assist with ADLs.There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.