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

We decided that the Plan does not have to pay for the treatment of a pelvic ring fracture services coded 27217 and 27216 provided on September 18, 2019.You asked the Plan to pay forthe treatment of a pelvic ring fracture services. You say that you would like the plan to reconsider their denial.The Plandenied 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 27217 and 27216 are not supported in the medical record. Specifically, codes 27217 and 27216 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, andpayment of these services. Based on this information, we decided that Medicare rules for coverage of the treatment of a pelvic ring fracture services have not been met.Therefore, we decided that the Plan does not have to pay forthe treatment of a pelvic ring fracture services coded 27217 and 27216 provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that the enrollee is at risk of progressive weakness without immediate aggressive therapy.The Plan denied your request. The Plan says there are no medical issues that requires an inpatient rehab physician 3 times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is at minimal assist for sit-to-stand, contact guard assist for chair transfers, and cueing or hand placement. She is very limited by fatigue and weakness. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. She may benefit and participate in additional physical and occupational therapy, but she does not require this and does not appear to tolerate this therapy on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that the enrollee is at risk of functional decline without immediate intensive therapy.The Plan denied your request. The Plan says there is no medical comorbidities to support the need for an inpatient rehab physician 3 times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's medical conditions appear stable. There are no wound care needs. He does not require medical oversight of his condition at an acute hospital level of care. There would be no expected need to modify the enrollee's treatment to maximize his capacity to benefit from rehabilitation. Physician supervision at an acute rehabilitation level of care would not be required. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, he does not require an intensive therapy program. The enrollee is limited by debility, recurrent episodes of dizziness, and the severity of his comorbid medical conditions. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.We looked at this physician's review, thefile, 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided by on September 5, 2019.You asked the Plan to waive the copayment forthe MRI. You say that you were unaware there would be a $200 copayment. You say you are on a fixed income and cannot afford the bill. 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 $200 copayment for diagnostic radiology other than CT scans. You have been asked to pay a $200 copayment for the MRI. The MRI falls 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 forthe MRI provided on September 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda, Alimta, and Carboplatin.You asked the Plan to pre-approveKeytruda, Alimta, and Carboplatin.You say that the requested Keytruda, Alimta, and Carboplatin are medically necessary.The Plan denied your request. The Plan says the requested Keytruda, Alimta, and Carboplatin are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda, Alimta, and Carboplatin. Our reviewer says that the requested Keytruda, Alimta, and Carboplatin are not medically necessary. Our physician reviewer found the enrollee presented with a mandibular metastasis that proved to be secondary to a T2N3M1 adenocarcinoma of the right lung. The requested use is second line treatment since the jaw lesion was metastatic and existed at the time the initial chemotherapy was given. The requested use of Keytruda, Carboplatin and Alimta is not FDA approved for use as second line treatment for metastatic non-small cell lung cancer (NSCLC). The combination is not supported in any of the CMSapproved compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, Alimta, and Carboplatin have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda, Alimta, and Carboplatin.
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 services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 currently undergoing treatment at an acute care hospital (ACH) for a psoas abscess and sepsis. The enrollee was intubated/ventilated upon hospitalization, but has since been extubated and is no longer on a ventilator. The enrollee is taking orals and 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 (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient level ofcare.You asked the Plan to pre-approveacute inpatient level of care. You say that the requested acute inpatient level of care is medically necessary.The Plan denied your request. The Plan says the requested acute inpatient level of care is notmedically 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 acute inpatient level of care. Our reviewer says that the requested acute inpatient level of care is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/15/20 diagnosed with altered mental status, lithium toxicity, and acute kidney injury. There was no documentation provided necessitating inpatient level of care services. The enrollee did not require or receive any inpatient diagnostic studies or therapeutic interventions. He was stable and appropriate for observation level of care services after the emergency room evaluation. The review has determined that the requested acute inpatient level of care is 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 acute inpatient level of care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient level of care.
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-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care with lower extremity swelling, acute kidney injury and falls. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee is noted to be minimally ambulatory at baseline. The enrollee's care needs can be met at a lower 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveQ-Tip cotton swabs.You asked the Plan to pre-approvecotton swabs. You say that the Plan should cover cotton swabsfor your wound care.The Plan denied your request. The Plan says cotton swabs are not covered by Medicare.The Plan covers all items that Medicare covers. Medicare rules state that cotton swabsare not covered because they are hygienic items that are non-reusableand available over the counterwithout a prescription. While cotton swabsmay be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveQ-Tip cotton swabs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on July 28, 2019, and July 29, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on July 28, 2019, and July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVyzulta ophthalmic solution for the enrollee.You asked the Plan to pre-approveVyzulta. You say that other medications have failed to control the enrollee's eye pressure.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 PartB 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-approveVyzulta ophthalmic solutionfor the enrollee.Benefits for Vyzultamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve continued care.You asked the Plan to pre-approvecontinued care with the physician. You say that the continuation of care with the physician is medically necessary.The Plan denied your request. The Plan says the continuation of care with the physician is not medically necessary and the enrollee can safely transition to an in-network neurologist.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 continued care with the physician. Our reviewer says that the continuation of care with the physician is not medically necessary and the enrollee can safely transition to an in-network neurologist. Our physician reviewer found the enrollee is diagnosed with multiple sclerosis (MS). The enrollee is now receiving Ocrevus as a disease modifying therapy. However that is only administered every 6 months (via infusion). The remainder of the management of the enrollee's condition at this stage is limited to monitoring her response to the therapy and symptomatic care/treatment. The enrollee is not otherwise under an active course of care/treatment/pharmacotherapy that cannot otherwise be managed by another neurologist. The enrollee has a history of multiple sclerosis. Management of this condition is standard within the practice of neurology. The plan has demonstrated that they have numerous neurologists available in their network within a reasonable geographic range (relative to the enrollee). As noted above, the enrollee does not have any unique 
circumstances associated with her condition at this time that would necessitate continuation of care with the current provider. Rather the enrollee's care (and ongoing management) could safely be transferred to an in-network provider.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued care with the physician have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued care with the physician
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmological medical examination and evaluation provided on September 4, 2019.You asked the Plan to pay for the ophthalmological medical examination and evaluation. You say that at no time did the provider advise you that he was no longer in-network. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an ophthalmological medical examination and evaluation provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 10, 2019
You asked the Plan to pay for vision services. You say that the provider  does not know which patients he will be
seeing since he is assigned to a facility. You say that this is why prior authorization was not obtained. The Plan
denied your request. The Plan says no prior authorization was obtained.
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 July 10, 2019 by
an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora duplex scan (93880) provided by "the medical center" on June 7, 2019.You asked the Plan to waive the coinsurance fora duplex scan. You say that the enrollee had diagnostic testing done on June 7 ,2019 and once the doctor reviewed the results on June 26, 2019 the enrollee was advised the test had to be done again. You say that since the enrollee had the same testing done twice you do not feel they should have to pay the coinsurance that applied of $43.93.The Plan denied your request. The Plan says outpatient diagnostic tests have a 20% coinsurance.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for outpatient diagnostic tests. The enrollee has been asked to pay a 20% coinsurance for a duplex scan. This servicefalls within the outpatient diagnostic tests benefit category. The allowable amount $219.67 x 20% = $43.93.This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora duplex scan (93880) provided by "the medical center" on June 7, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services. You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires continued cardiac monitoring, rehab therapy, and daily physician visits.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.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 physician reviewer found that the enrolleeis currently undergoing treatment at an acute care hospital (ACH) for COPD, pneumonia and renal failure. The enrollee has received antibiotics and been started on hemodialysis. The enrollee was transiently intubated/ventilated, but is no longer 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.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.