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

We decided that the Plan does not have to pay forthe services (CPT 37186) provided on October 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rulessay 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 37186 is "Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure)".We asked our coding 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 services. Our reviewer says that the use of CPT code 37186 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of a "Secondary percutaneous transluminalthrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy" being performed on October 25, 2019, therefore this service cannot be verified.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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 37186) provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient therapy provided from January 3, 2020 through January 16, 2020.
You asked the Plan to waive the deductible for outpatient therapy. You say that you were informed you were covered and would owe $0. The Plan denied your request. The Plan says the deductible applied correctly.
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 your combined deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services. Outpatient therapy isn't excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to outpatient therapy. This cost sharing is a contractual obligation that had not been met at the time outpatient therapy was received on January 3, 2020 to January 16, 2020. Therefore, we decided that the Plan does not have to waive the deductible for outpatient therapy provided from January 3, 2020 through January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.
You asked the Plan to pre-approve a lightweight wheelchair. You say that you need the wheelchair for safety as you cannot walk and have no stability. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a standard wheelchair. A standard wheelchair serves the same purpose as a lightweight wheelchair. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
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 admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications. The enrollee had stable vital signs. The enrollee required stand-by assistance with functional mobility including walking to 60 feet with a rolling walker. The enrollee required varying assistance with activities of daily living. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF admission 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: 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 needs this care to regain strength. The Plan denied your request. The Plan says the enrollee's care can be provided in 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 based on the provided medical records the patient is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on January 7, 2020.
You asked the Plan to pay for the resin-based composites. You say that prior to having these services rendered, your dentist contacted the Plan and was faxed a breakdown of your 2020 dental benefits. The Plan denied your request. The Plan says this is not 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, comprehensive dental care benefits are available for purchase under Optional Supplemental Benefits. The record shows that your 2020 dental plan does not show that you enrolled in the optional benefit that covers comprehensive dental services. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveRepatha  Sureclick  for the  enrollee.You asked the  Plan to pre-approvethis  drug.  You  say that this  is  medically  necessary  for  the  enrollee.The  Plan denied  your  request.  The  Plan  says that  this  drug  is self-administered  and  not covered  under  the  medical benefit.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-approveRepatha  Sureclick  for  the enrollee.Benefits for this  drugmay  be available  under Medicare Part D.Contactthe  Plan  that  administers  Part D benefits  for further  information  concerning  any  benefits  and appeal  rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from January 23, 2019 to January 27, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you disagree with the charge. You say you should be reimbursed for the $275 you paid up front. 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 for each day for days 1 to 8 for in-network Medicare-covered hospital care. You have been askedto pay a $250 copayment for each day the inpatient hospital stay. ($250 x 4 days = $1,000). The inpatient hospital stay falls within the "Inpatient Hospital Care" 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 inpatient hospital stay provided from January 23, 2019 to January 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) for the enrollee.
You asked the Plan to pre-approve MRS. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare has determined that the evidence is not adequate to conclude that MRS is reasonable.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that MRS is not yet a covered service. There is not enough evidence to support the requested imaging service. Based on this information, we decided that Medicare rules for coverage of MRS have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.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 services, or home with outpatient 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 enrollee was medically stable with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally, you are at minimum to CGA level, and does not need IRF admission. You may benefit from further PT and OT but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.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) for the enrollee.
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 this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee safely receive the services needed in other settings.
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. The patient's current medical status does not require intensive physician or nursing oversight in an IRF. The patient may benefit from additional multiple therapies; however, the patient's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a high frequency chest wall oscillation system.
You asked the Plan to provide a high frequency chest wall oscillation system. You say that the daily use of this device will result in fewer hospitalizations, respiratory infections and antibiotic usage. The Plan denied your request. The Plan says the record shows the enrollee does not have a qualifying diagnosis.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to provide a high frequency chest wall oscillation system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.You asked the Plan to pre-approve the drug. You say that the enrollee is out of medication and wants to prevent falling and getting a fracture.The Plan denied your request. The Plan says the benefit provides coverage for requested drug when medically necessary.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. The drug has been approved under the enrollee's Part D plan therefore it is not approved under Part B also. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe for the enrollee.
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 you are appealing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. While the enrollee may benefit from additional multiple therapies, the enrollee's functional level which is noted to have fair endurance does not require or indicate that this therapy must be provided in an IRF with an intensive level program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the colostomy supplies provided on March 14, 2020.
You asked the Plan to waive the coinsurance for the colostomy supplies. You say that you have never had to pay for these supplies before. 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 $50.31 which is 20% of the allowed amount for the colostomy supplies. The allowed amount is $251.57. ($251.57 x 20% = $50.31). The colostomy supplies fall within the "Prosthetic devices and related supplies" 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 colostomy supplies provided on March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided December 26, 2019.You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that the enrollee previously received this same item from a different provider on October 15, 2018. Since there is no evidence that the braces that the enrollee received in 2018 were lost, stolen, or destroyed, coverage is not allowed for replacement of the orthosis.Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided December 26, 2019.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve VENETOCLAX. We decided that the Plan does not have to pre-approve GAZYVA.You asked the Plan to pre-approve these services. You say that delaying treatment will lead to a decline in the enrollee's health. The Plan says that the services are not medically necessary.We decided that the Plan has to pre-approve VENETOCLAX.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 these services. Our reviewer says that the VENETOCLAX is medically necessary and the GAZYVA is not medically necessary. Our physician reviewer found the enrollee has chronic lymphocytic leukemia (CLL) and has received 12 cycles of treatment. The requested combination is fifth line therapy. GAZYVA is not FDA-approved or compendium supported for the requested use. GAZYVA is not reasonable or medically necessary or safe and effective.VENETOCLAX is supported by the National Comprehensive Cancer Network (NCCN) compendium as a single agent to treat CLL that is relapsed or refractory. The VENETOCLAX is therefore reasonable and medically necessary and is safe and effective.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of VENETOCLAX have been met. Therefore, we decided that the Plan has to pre-approve VENETOCLAX. We also decided that the Plan does not have to pre-approve GAZYVA.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gazyva have not been met. Therefore, we decided that the Plan does not have to pre-approve GAZYVA. 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.