Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for hypovolemic shock and third spacing in the setting of end-stage renal disease. The enrollee is receiving vasoactive medications and hemodialysis. The enrollee is not intubated/ventilated. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex device.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have chronic low back pain and nerve root pain in the legs. There is no documented instability. There is no need for a Coflex device. The services are considered experimental/investigational in nature and are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex device.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for the bone density scan provided on March 4, 2019.
You asked the Plan to hold you harmless for the bone density scan. You say that you were told that this was needed and based on the results of the scan, you were put on a new medication to treat your bone density. The Plan denied your request. The Plan says that this is only covered once every two years as noted in your contract. The records provided do not show a diagnosis which supports doing this scan earlier than two years after the scan provided in January 2018.
The Plan must follow Medicare rules. The rules say that a Cost plan must cover items or services if an enrollee: 1. Received the items or services under the direction or authorization of a plan physician; 2. Correctly identifies himself or herself as a member of that plan to the contract provider before receiving the items or services; and 3. Has not been informed that he or she is liable for the cost of such items or services. You were referred for the bone density scan by the physician. The physician is a contract provider with the Plan. The file does not show that you failed to correctly identify yourself to the physician as a member of the Plan before receiving the bone density scan. The file does not show that the Plan provided notice that the bone density scan would not be covered. The contractual language does allow for coverage of more frequent scans if medically necessary. As such, the contract cannot be considered sufficient notice that this would not be covered. Therefore, we decided that the Plan has to hold you harmless for the bone density scan provided on March 4, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for aspiration resulting in a cardiac arrest. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. He has since been weaned from the ventilator and is participating in rehabilitative services. 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.
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. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for renal failure. The enrollee has been started on hemodialysis. The enrollee is not intubated/ventilated. 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.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a replacement socket.
You asked the Plan to pre-approve a replacement socket. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a replacement socket is considered reasonable and necessary if there is adequate documentation of functional and/or physiological need. 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 a replacement socket. Our reviewer says that a replacement socket is medically reasonable and necessary. Our physician reviewer found that the enrollee is an amputee, who has used a prosthetic since the age of three. The enrollee is noted to have two prosthetics, a microprocessor one for everyday use and one for use when wearing restrictive footwear (i.e. boots) and/or when her limb might get wet (i.e. rain, snow). The enrollee is requesting that the socket of her second prosthetic be replaced as it is worn and no longer fitting properly. The use of this second prosthetic does not appear to be primarily for comfort or convenience. The use of this second prosthetic allows the enrollee to tend to ADLs, which she otherwise would not be able to tend to with her primary prosthetic. The enrollee is noted to be very active and to have experienced changes in the residual limb (i.e. weight loss). Therefore, the replacement socket set is shown to be medically necessary and 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 a replacement socket have been met. Therefore, we decided that the Plan has to pre-approve a replacement socket.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 8, 2019 to September 12, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a Treatment Authorization Code is necessary to be indicated on the claim for payment purposes.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim that was submitted does not include the required Treatment Authorization Code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 8, 2019 to September 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the phlebotomy services provided from February 13, 2019 to August 2, 2019.
You asked the Plan to reduce the copayments for the phlebotomy services. You say that you do not know why your bill has changed from a $21 copayment to a $121 copayment. 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 $350 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the phlebotomy services.
You have been asked to pay a $109.16 copayment for each of the phlebotomy services. The phlebotomy services fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 reduce the copayments for the phlebotomy services provided from February 13, 2019 to August 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for drugs received on November 18, 2019 and November 25, 2019.
You asked the Plan to waive the coinsurance for the drugs. You say that you should not have to pay any additional coinsurance. The Plan denied your request. The Plan says the coinsurance was applied correctly according to your benefits and the services rendered.
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 Medicare Part B covered drugs. You have been asked to pay 20% coinsurance for the drugs. The drugs fall within the Medicare Part B covered drugs 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 drugs received on November 18, 2019 and November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307) provided on September 10, 2019 by an out of network provider.
You asked the Plan to pay for drug testing. You say that upon review you found that the service was medically necessary for the patient's condition. You have attached the medical records for consideration. The Plan denied your request. The Plan says this doctor is a non-par provider and the referring provider is also a non-par provider. The record shows that there were participating providers in the area that were available at the time the service was rendered by the non-par 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. 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 drug testing (80307) provided on September 10, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl Dis 75mcg/HR for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Fentanyl Dis 75mcg/HR for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered to the enrollee on January 22, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77062 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The provider submitted a claim for procedure code 77062 (bilateral digital breast tomosynthesis). This code has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the digital breast tomosynthesis rendered to the enrollee on January 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve Eliquis. You say that the enrollee could get another pulmonary embolism. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Eliquis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 1, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you should not owe a copayment for lab services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $0 copayment for bloodwork drawn and processed at a physician's office and a $10 copayment for bloodwork drawn at a physician's office and sent to an independent lab for processing. The record shows that you had labs processed at an independent lab on October 1, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $0 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 30 minutes of advance care planning (99498) provided on July 5, 2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says add-on code 99498 was not billed with an acceptable primary procedure code eligible for payment.
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, CPT code 99498 is an add-on code and cannot be billed without an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an additional 30 minutes of advance care planning (99498) provided on July 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (CPT 95810)
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says CPT 95811 has already been approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria for diagnostic PSG, CPT 95810, are not met. According to the case summary, this enrollee has a past history of central sleep apnea, but a non-diagnostic home PSG. The Plan has approved CPT 95811, split-night PSG with PAP titration, which is the most appropriate study for this enrollee. 95810 would duplicate the diagnostic portion of 95811, and is therefore not medically 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (CPT 95810)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 1, 2018 to October 15, 2018.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the physical therapy revenue code was billed without a required billed Q code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim that was submitted does not include the required Q code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 1, 2018 to October 15, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam and refraction rendered to you on April 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for areconsidered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay forthe routine eye exam and refraction rendered to you on April 18, 2019.