Persius/hicric huggingface dataset:
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 needs can be met at a lower level of care, such as a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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's care needs can be met at a lower level of care (ex. SNF/SAR).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardiMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due to his worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because further study is needed to determine the safety and efficacy of CardioMEMS.
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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found CardioMEMS device implantation has been shown in limited clinical trials to improve symptoms and decrease re-hospitalization in patients with heart failure and recent hospitalization for chronic heart failure decompensation. In this instance the hospitalization was not primarily for treatment of heart failure. As the enrollee is reportedly on a stable medical regimen without physical examination signs of chronic heart failure and his recent admission was primarily to treat a different diagnosis, he would not meet the clinical indications for CardioMEMS device implantation 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardiMEMS procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc One. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has a history of osteoarthritis of the left knee. The documentation does not support that the enrollee has tried and failed the required drugs of Euflexxa, Supartz Fx, Durolane, or Gelsyn-3. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on October 27, 2020.

You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no personal history of cancer.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve
BRCA 1 and 2 testing for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (CPT code 90834) provided on October 20, 2020, by a Licensed Professional Counselor (LPC).

You asked the Plan to pay for the services. You say that you were referred by your Primary Care Provider (PCP) and were unaware that you were going to an out-of-network provider. The Plan denied your request. The Plan says they contacted your PCP and were told by your PCP there is no record of a referral to this provider.

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.

This type of provider is not eligible to enroll in the Medicare program. Furthermore, the Plan stated they contacted your PCP who told the Plan that the services were not referred. Therefore, we decided that the Plan does not have to pay for psychotherapy (CPT code 90834) provided on October 20, 2020, by a Licensed Professional Counselor (LPC).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.

You asked the Plan to pre-approve PET scan. You say that other tests have shown nothing, so you would like to have this PET scan done to rule out malignancy.The Plan denied your request. The Plan says the denial of authorization for this PET scan is correct, because this imaging is not supported for the enrollee's indication.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the enrollee does not have a malignancy diagnosis. Therefore, the requested PET scan cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D9999, D2740 x 2) received September 9, 2020.

You asked the Plan to pay for the dental services (D9999, D2740 x 2). You say that you have a $1,000 dental benefit allowance that should be applied to the claim. The Plan denied your request. The Plan says you have exhausted your $1,000 dental benefit allowance in this claim.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested payment is in excess of those covered under this benefit. The Plan has submitted evidence that your $1,000 allowance was exhausted in the claim in dispute. The Plan issued a $1,000 check for reimbursement to you on October 7, 2020. You are responsible for any amount charged by your provider over the $1,000 benefit allowance. Therefore, we decided that the Plan does not have to pay for the dental services (D9999, D2740 x 2) received September 9, 2020.
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 necessary because you cannot be safely discharged home. The Plan denied your request. The Plan says your needs can be met in the current IRF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you have identifiable skilled nursing service needs. While you have skilled therapy needs, you do not require skilled therapy services on a daily basis. You do 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99213, 99203, 99204, 99214) to be provided by an out of network (OON) plastic surgeon.
You asked the Plan to pre-approve OON office visits. You say that no other surgeon in the area who can perform the procedure you need. The Plan denied your request. The Plan says there are in network providers who are able to provide these services within a reasonable distance from your location.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits (99213, 99203, 99204, 99214) to be provided by an out of network (OON) plastic surgeon.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on September 9,
2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a
covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 ambulance services. Our reviewer says
that the requested ambulance transportation is not medically reasonable and necessary. Our physician reviewer
found that the enrollee was transported from a nursing facility to a scheduled urology appointment non-urgently.
He could not ambulate or get out of bed without assistance and could not sit in a wheelchair. His
vitals were normal and did not require any treatment during transportation. The documentation does not
support that a stretcher van was contraindicated in this instance. The documentation does not support that the
enrollee needed expertise and special services and equipment during transport. The documentation does not
support that the ambulance transportation service was medically necessary 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 ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the ambulance transportation provided on September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you were admitted for surgical repair of a hip fracture. Your medical problems are
stable. You do not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for foot x-ray (CPT code 73620), transport portable x-ray (CPT Code R0070), and set-up portable x-ray equipment (CPT Code Q0092) provided to the enrollee on October 30, 2020, by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is not in-network with the Plan and the referring provider is also not in-network with the Plan. The Plan states the services are not considered urgent/emergent in nature.

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 had network providers available who could have provided 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 foot x-ray (CPT code 73620), transport portable x-ray (CPT Code R0070), and set-up portable x-ray equipment (CPT Code Q0092) provided to the enrollee on October 30, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extension of inpatient psychiatric care.
You asked the Plan to pre-approve additional inpatient psychiatric care. You say that the requested services are necessary care for you. The Plan denied your request. The Plan says rules for inpatient psychiatric care have not been met.
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 additional inpatient psychiatric care. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that you were admitted to acute inpatient psychiatric hospitalization on April 5, 2021, with Bipolar Disorder, Current Episode Depressed, Severe with Psychotic Features. Based upon review of the records provided, it is not expected you would improve in a reasonable period of time beyond the dates already approved by the Plan, as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve an extension of inpatient psychiatric care.
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 level of care. The Plan denied your request. The Plan says the denial of authorization for LTACH is correct.
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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH 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-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 2, 2020.

You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on March 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive medication services, per 15 minutes (CPT code H2010) provided from October 1, 2020, through October 8, 2020, by an out-of-network provider.

You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. The Plan states the treating providers are out-of-network and they are also billing with H codes which is not recognized my Medicare.

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 had network providers available who could have provided 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 comprehensive medication services, per 15 minutes (CPT code H2010) provided from October 1, 2020, through October 8, 2020, by an out-of-network provider.