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

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 2, 2019 through September 5, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need 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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 2, 2019 through September 5, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical nerve stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of psychological treatment or a favorable evaluation.
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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there was no documentation provided for review to support that you had undergone a psychological evaluation to date (for the requested procedure). There were no documents provided from a psychologist. In the absence of such documentation, the requirements for coverage as set-forth by the NCD would not be considered to be satisfied. Therefore the requested SCS trial would not be 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical nerve stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 19, 2019 through October 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need 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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that 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 emergency department (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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 19, 2019 through October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99053) provided on October 31, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says separate payment cannot be made for this service.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99053 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99053). 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 99053)provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management services provided to enrollee from July 4, 2019 to September 16, 2019.You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.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 99354 is prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service).We find that CPT code 99354 is not supported in the medical record. Specifically, the documentation does not support that additional time was spent with the enrollee beyond the services of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management services provided to enrollee from July 4, 2019 to September 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, an ER visit and does not have to waive the coinsurance for a Medicare Part B drug provided on September 24, 2019 and October 10, 2019.You asked the Plan to waive the copayment for myocardial perfusion imaging, an ER visit and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges.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 $100 copayment for diagnostic radiology provided by non-primary care providers. Your contract with the Plan also clearly says that you must pay a $90 copayment for emergency care. Your contract with the Plan also clearly says that you must pay20% coinsurance for Medicare Part B prescription drugs.You received myocardial perfusion imaging on September 24, 2019. Therefore, you are responsible to pay the $100 copayment. You received a Medicare Part B drug on September 24, 2019. The allowed amount is $225.24 and 20% of that is $45.05. You received an ER visit on October 10, 2019. Therefore, you are responsible to pay the $90 copayment. The total amount you owe is: $235.05.You have been asked to pay the total amount of $235.05 for myocardial perfusion imaging, an ERvisit and a Medicare Part B drug. Myocardial perfusion imaging, falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. An ER visit falls within the emergency care benefit category. A Medicare Part B drug falls within theMedicare 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 copayment for myocardial perfusion imaging, an ER visit and does not have to waive the coinsurance for a Medicare Part B drug provided on September 24, 2019 and October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December 4, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be responsible for the copayment because you were only told to take an over-the-counter medication. 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 $15 copayment per visit for in-network urgently needed care. You have been asked to pay a $15 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you were evaluated and treated during your urgent care visit.
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 the urgent care visit provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 to the enrollee by an out of network (OON) provider.
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 the services were rendered by an out-of-network provider without 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 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 September 12, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the test supports optimal treatment planning, improves enrollee outcomes, and ultimately reduces healthcare costs.The Plan denied your request. The Plan says utilization of network providers and authorization for certain services is required.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 services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that thePlan does not have to pay forthe lab services provided to the enrollee on November 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulation treatments.You asked the Plan to pre-approve these services. You say that you are in extreme pain and chiropractic treatment helps.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have narrowing of the spine (stenosis), a condition for which chiropractic treatment can do little and is not recommended. There is no documentation of a subluxation of the spine in the records. Thus, chiropractic treatment is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulation treatments.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your
request. The Plan says the proposed treatment is considered investigational, per the medical literature.
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 block. Our reviewer says that the
requested block is not considered medically reasonable and necessary in this case. Our physician reviewer
found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically
necessary for the treatment of chronic knee pain, including, but not limited to any of the following:
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement
surgery. The requested genicular nerve block is not medically reasonable and 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 block have not been met. Therefore, we decided that the Plan does not have
to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee uses FreeStyle test strips. The Plan denied your request. The Plan says the information submitted does not meet Plan medical necessity guidelines.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (99213, 98943, 97110, 97035, 97014 and 97010).
You asked the Plan to pre-approve the chiropractic services.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records do not show evidence of subluxation or fracture.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 chiropractic services. Our reviewer says that there are no submitted imaging studies to reveal evidence of a subluxation and the submitted chiropractic office visit note does not support evidence of subluxation. Our physician reviewer found chiropractic treatment is neither supported nor allowed per Medicare guidelines. 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 chiropractic services. have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (99213, 98943, 97110, 97035, 97014 and 97010).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888) provided on October 30, 2019.
You asked the Plan to waive the cost-share for the services. You say that you took the ambulance from the city to the rehab because the facility is closer to your family and you depend on your family's help. The Plan denied your request. The Plan says this was not the closest facility you could have been taken to.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888) provided on October 30, 2019. You are asked to pay a $265 copayment for the ambulance services. Your e also states that services are EOC also states, services are covered to the nearest appropriate facility which is the reason of denial for service A0888 for the amount of $462. Both amounts sum the total of $727. 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 cost-share for noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888) provided on October 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDronabinol.You asked the Plan to pre-approveDronabinol. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Dronabinol is not covered under the enrollee's Medicare Part B 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-approveDronabinol.Benefits for Dronabinolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemanipulation under anesthesia torestart wrist motion (25259).You asked the Plan to pre-approvemanipulation under anesthesia to restart wrist motion (25259). You say that the requested manipulation under anesthesia to restart wrist motion is medically necessary.The Plan denied your request. The Plan says the requested manipulation under anesthesia to restart wrist motion is 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 manipulation under anesthesia to restart wrist motion (25259). Our reviewer says that the requested manipulation under anesthesia to restart wrist motion is not medically necessary. Our physician reviewer found the enrollee is status post open reduction and internal fixation left comminuted distal radius fracture and subsequent hardware revision. She is indicated for hardware removal. Under consideration is a request for manipulation under anesthesia ofthe left wrist to restart motion. There are no large volume long term peer-reviewed outcome studies to support the use of manipulation under anesthesia in this enrollee's medical condition. Active/passive range of motion has not been documented. This enrollee does not have a diagnosis, condition, and/or symptoms to support the medical necessity of wrist manipulation under anesthesia at this time, and this would not be considered the standard of care for her medical condition. Therefore, it would not be considered medically reasonable and necessary for this enrollee to have wrist manipulation under anesthesia as requested.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of manipulation under anesthesia to restart wrist motion (25259) have not been met.Therefore, we decided that the Plan does not have to pre-approvemanipulation under anesthesia to restart wrist motion (25259).