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

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says ongoing care can be provided in a lower level of 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheotomy care with ventilator management, respiratory treatments, tube feedings, catheter care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvebariatric surgery.You asked the Plan to pre-approvebariatric surgery. The Plan denied your request. The Plan says that the coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35; (2) at least one co-morbidity related to obesity; and(3) been unsuccessful with medical treatment for obesity.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin denying the request to pre-approve bariatric surgery. Our reviewer says that the requested bariatric surgery is medically reasonable and necessary. Our physician reviewer found the enrollee is an adult with BMI that is greater than 35 kg/m2 and more than one obesity related condition and failed efforts at medical weight loss. The enrollee meets all CMS criteria for bariatric surgery 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 bariatric surgery have been met.Therefore, we decided that the Plan has to pre-approvebariatric surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from September 14, 2019 to September 21, 2019.
You asked the Plan to pay for these services. You say that this should be covered as it is a valid procedure code according to Medicare. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from September 14, 2019 to September 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTravatan for "the beneficiary". You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the enrollee is stable on this medication.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-approveTravatan for "the beneficiary". Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProlia injections.You asked the Planto pre-approvethe Prolia. You say that the enrollee is not able to take oral bisphosphonates and zoledronic acid is not recommended due to her reduced kidney function.The Plandenied your request. The Plansaysthe enrollee's kidney function is high enough to tolerate zoledronic acid.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 the Prolia. Our reviewer says that the requested drug is not considered reasonable and necessary due to step therapy requirements. Our physician reviewer found the enrollee is a female with a history of osteoporosis including wrist fracture and thoracic compression fracture. There is no evidence that the enrollee has tried and failed oral bisphosphonates or zoledronic acid. The provided medical records do indicate that the patient would not be able to tolerate oral bisphophonates due to positioning required for these drugs. The records do not indicate that zoledronic acid would likely be less effective and/or likely have adverse effects for the patient -the medical records include a lab report of 10/21/19 indicating her glomerular filtration rate isat least 70 ml/min. This is sufficient for treatment with zoledronic acid.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 2, 2019, to July 3, 2019.You asked the Plan to pay forthe acute inpatient hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient toneed hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment aremet in this case. Our physician reviewer found that the enrollee was a then 79-year-old female with a history of HTN, CHF, and Colon Ca who presented to the ED on July 2, 2019, with chest pain that radiated to the left upper and lower extremities. The evaluation revealed bradycardia and chest wall pain to palpation. The EKG was without any acute ischemic changes and the lab studies were remarkable for an abnormal urinalysis. She was admitted to telemetry and she was treated with oral medications. Her condition stabilized and improved and she was discharged home on July 3, 2019. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 2, 2019, to July 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 95937) provided on July 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the documentation does not support the billed code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriateCPT code.In this case, the CPT Code Manual definition of code 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method".We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 95937 is not supported by the records provided. Our coding reviewer found that the medical records provideddo not document Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The provided medical documentation indicates train of four testing was performed. It is not appropriate to bill CPT 95937 to represent trainof four testing per Medicare and AMA guidelines. There is no separate code for Train of Four Monitoring. Train of Four monitoring is bundled with intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and should not be reported separately.We looked at this coder'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 95937) provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotics rendered on August 16, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the orthotics rendered on August 16, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections.
You asked the Plan to pre-approve the Prolia injections. You say that the enrollee has a history of GI issues and esophageal dilation which would not allow for treatment with oral bisphosphonates. The Plan denied your request. The Plan says the enrollee must have a history of osteoporotic fracture and have failed zoledronic acid to be eligible for coverage of Prolia.
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 the Prolia injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has a history of osteoporosis. There is no documented failure of zoledronic acid, the preferred drug. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laser vaporization of the prostate (52648).You asked the Plan to pre-approve a laser vaporization of the prostate. You say that this should be covered.The Plan denied your request. The Plan says this is not medically reasonable and 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 a laser vaporization of the prostate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not provide adequate information that the patient has significant benign prostatic hyperplasia (BPH) and BPH related symptoms. Surgical intervention such as laser vaporization of the prostate is an appropriate treatment alternative for patients with moderate-to-severe lower urinary tract symptoms and for patients who have developed acute urinary retention or other BPH-related complications. By definition, surgery is the most invasive option for BPH management and generally, patients will have failed medical therapy before proceeding with 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 a laser vaporization of the prostate have not been met.Therefore,we decided that the Plan does not have to pre-approvea laser vaporization of the prostate (52648).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient clinic visits provided on August 2, 2019, August 20, 2019 and October 14, 2019.
You asked the Plan to waive the coinsurance for the outpatient clinic visits. You say that you were not able to see a new psychiatrist. You say that the provider should be covered at the hospital. 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 40% of the total cost for out-of-network outpatient mental health care. You have been asked to pay $49.23, which is 40% of the allowed amount for each clinic visit. The allowed amount is $123.07 (40% x $123.07 = $49.23). The total amount you owe is $147.69 ($49.23/visit x 3 visits = $147.69).
The outpatient clinic visits fall within the "Outpatient mental health care" benefit category. The records show that the clinic visits were provided at an out-of-network facility. 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 outpatient clinic visits provided on August 2, 2019, August 20, 2019 and October 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mavenclad for the enrollee.
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 self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mavenclad for the enrollee.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan.  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 self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan.  Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 3, 2019 by the out of network provider.
You asked the Plan to pay for an electroretinography. You say that you would like the medical records reviewed and payment reconsidered. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the facility is also out-of-network. The Plan says that 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 3, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin/Atezolizumab/Paclitaxel/Ondansetron/Dexamethasone/Zoledronic acid drug regimen.
You asked the Plan to pre-approve the regimen. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug regimen requires use with Albumin-bound paclitaxel.
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 the regimen. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found you are progressing on single agent atezolizumab. Continuation of immunotherapy after progression is not a standard of care. Therefore, the combination of the requested drugs would not be indicate for 2nd line treatment after progression. The service is 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 the regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin/Atezolizumab/Paclitaxel/Ondansetron/Dexamethasone/Zoledronic acid drug regimen.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 22, 2019 to September 29, 2019.You asked the Plan to pay for the home infusion therapy services. 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.In this case, the CPT Code Manual definition of code S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is 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 home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from September 22, 2019 to September 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laser surgery provided on July 17, 2019 by out of network provider. You asked the Plan to pay forlaser surgery. You say that you were told authorization was not needed for this service.The Plan denied your request. The Plan says services provided out-of-network require 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 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 services.Therefore, we decided that the Plan does not have to pay forthe laser surgery provided on July 17, 2019.