Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that that the requested services are medically necessary. 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 that 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 was admitted for seizure and ventricular fibrillation/cardiac arrest. The enrollee does 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for computed tomography (CT) head or brain (70450) Duplex scan of extremity veins including responses to compression and other maneuvers (93970) provided November 2, 2020.
You asked the Plan to waive the coinsurance for the diagnostic services. You say that it is your understanding with your Medicare/medical benefit that you do not have co-insurance. You have never paid anything out of pocket before. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 covered complex diagnostic radiological services. You have been asked to pay $14.27 for the diagnostic services. The diagnostic 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 coinsurance for computed tomography (CT) head or brain (70450) Duplex scan of extremity veins including responses to compression and other maneuvers (93970) provided November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L2397, L1851) provided on November 6, 2020.
You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider prescribes orthoses without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthoses have not been met. Specifically, the Plan attests that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L2397, L1851) provided on November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white cane.
You asked the Plan to pre-approve the cane. You say that this is medically necessary, as you have visual loss in
both eyes. The Plan denied your request. The Plan says there is no coverage for white canes.
The Plan must follow Medicare rules. The rules say that white canes are not covered, as they are not considered
mobility assistive equipment.
The requested cane is statutorily not covered. Based on this information, we decided that Medicare rules for
coverage of the cane have not been met. Therefore, we decided that the Plan does not have to pre-approve a
white cane.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy and laboratory services (45385, 45380, 88305, 84460, 80061, 36415) provided on January 9, 2020 to March 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the colonoscopy and laboratory services. You say that you would like reconsideration because you believed these providers accepted your insurance. The Plan denied your request. The Plan says your Primary Care Physician did not give referrals for either of these services and the medical group and the performing doctors did not have an authorization approval.
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 the colonoscopy and laboratory services (45385, 45380, 88305, 84460, 80061, 36415) provided on January 9, 2020 to March 17, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketamine.
You asked the Plan to pre-approve Ketamine. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Ketamine. Our reviewer says that the medication is not medically necessary. Our physician reviewer found this would be an experimental/ investigational off label use of this medication. Therefore, the request is considered not medically reasonable or 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 Ketamine have not been met. Therefore, we decided that the Plan does not have to pre-approve Ketamine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the enrollee does not appear to require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to participate in fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's 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-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye exam (92014) and the scanning computerized ophthalmic diagnostic imaging (92134) performed January 7, 2020.
You asked the Plan to pay for the vision care services. You say that the claim processed incorrectly due to the Plan's error and you were instructed to resubmit the claim for reprocessing. The Plan denied your request. The Plan says that coverage must be obtained from a network 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. We looked at the file and the Plan's rules. We contacted the Plan to determine the network status of the provider on the date of service at issue. The Plan has stated that the provider was considered in network at the time the services were performed on January 7, 2020. Based on this information, we decided that the Plan's rules for coverage of the vision care services have been met. Therefore, we decided that the Plan has to pay for the eye exam (92014) and the scanning computerized ophthalmic diagnostic imaging (92134) performed January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET/CT scan described by code 78815 provided on December 11, 2020.
You asked the Plan to pay for code 78815. You say that the medical records support the billing of code 78815. The Plan denied your request. The Plan says the medical records do not support the billing of code 78815.
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 pay for code 78815. Our reviewer says that the medical records do not support the billing of code 78815. Our physician reviewer found in this case; the enrollee underwent a PET scan from skull to mid-thigh. The provider submitted documentation to show why the test was performed. The elements of the coverage determination are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 78815 have not been met. Therefore, we decided that the Plan does not have to pay for the PET/CT scan described by code 78815 provided on December 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN in the home health or hospice setting (G0299).
You asked the Plan to pre-approve the direct skilled nursing services of a RN. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for the requested skilled nursing services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 direct skilled nursing services of a RN. Our reviewer says that these services are not shown to be medically necessary or reasonable. Our physician reviewer found the enrollee is not home bound. Blood draws are not an indication for home health services. Our reviewer also found that the enrollee's needs are custodial.
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 direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a RN in the home health or hospice setting (G0299).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of an assistant-at-surgery during anterior lumbar diskectomy and lumbar interbody fusion (22558, 22585 and 22853) provided on August 5, 2020.
You asked the Plan to pay for the services on an assistant-at-surgery. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says this claim cannot be reprocessed for payment until a corrected claim with modifier 62 is received. Please note, we have decided that this is not a valid denial as this service is being billed by the assistant-at-surgery.
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 pay for the services on an assistant-at-surgery. 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 on an assistant-at-surgery have not been met. Therefore, we decided that the Plan does not have to pay for the services of an assistant-at-surgery during anterior lumbar diskectomy and lumbar interbody fusion (22558, 22585 and 22853) provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not meet the Medicare criteria for a therapeutic CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for coverage of an Intracept procedure are not met because the requested service is considered experimental/investigational.
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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure remains experimental for low-back pain. More research is needed to show the safety and efficacy of the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
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: at a skilled nursing facility or at home with home health services.
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 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 was admitted for weakness, fall and hypertension and was discharged home on 4/13/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this enrollee 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 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 waive the coinsurance for the topical administration of aminolevulinic acid provided on October 14, 2020.
You asked the Plan to waive the coinsurance for the topical administration of aminolevulinic acid. You say that you went through all the proper protocol to be sure this treatment was fully covered. You say that the doctor's office and insurance did not disclose any charges you would be responsible for. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the plan-allowed amount for Medicare Part B-covered drugs from an in-network provider. You have been asked to pay $157.90, which is 20% of the allowed amount for the topical administration of aminolevulinic acid. The allowed amount is $789.50 (20% x $789.50 = $157.90). The topical administration of aminolevulinic acid falls within the "Medicare Part B prescription 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 the topical administration of aminolevulinic acid provided on October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs are primarily custodial.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. Further rehab services can be received at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.