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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure which required intubation/ventilation. The enrollee has since been extubated and is no longer on a ventilator. The enrollee has since been determined to have some form of metastatic cancer, which is being further evaluated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires aggressive pulmonary hygiene, rehab therapy, and daily physician visits. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 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 oxygen supplementation, respiratory hygiene and bronchodilators, fluid balance with intravenous diuretics, surveillance laboratory studies, antibiotics, 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 22, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 22, 2019. You attached medical records to support medical necessity as an authorization was not obtained. The Plan denied your request. The Plan says your doctor is a non-participating provider. The Plan did not authorize services for a surgery or this provider. The services are not considered urgent/emergent in nature.
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 an office visit (99213) provided on August 22, 2019 by the out of network provider.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.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 thecase 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not revealthat the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee does not require this 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided to the enrollee by an out of network provider.
You asked the Plan to pre-approve the out-of-network services. You say that without treatment, the enrollee's condition will continue to worsen. The Plan denied your request. The Plan says the service is available within the enrollee's network.
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 pre-approve 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. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided to the enrollee by the out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the office visit provided on May 14, 2019.
You asked the Plan to waive the coinsurance for the office visit. You say that the doctor did not do anything. You say that you want help with payment. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for the podiatry office visit. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for the podiatry office visit. The Plan contract does not clearly say when enrollees should expect to pay a $0 copayment and when enrollees should expect to pay 20% coinsurance. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the office visit provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on February 12, 2019 by an out of network provider.
You asked the Plan to pay for podiatry services. You say that you followed all the rules. You say that you wanted a second opinion because your doctor wasn't aware of the side effects of the medication that your doctor wanted to prescribe you. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 podiatry services provided on February 12, 2019 by the out of network provider.
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-approve IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.
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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee does not require this 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on July 29, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code G0481 that should be used to bill for service rendered.
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 HCPCS code G0483 is "definitive drug testing, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, including, but not limited to, GC/MS and LC/MS and excluding immunoassays and enzymatic methods; qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class (es), including metabolite(s) if performed." 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. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the review has determined that there was a more appropriate Healthcare Common Procedure Coding System (HCPCS) code G0481 that should be used to bill for service rendered. The review has determined that the records did not support the coding of HCPCS G0483. The documentation submitted indicate that definitive, utilizing drug identification methods with less than 22 drug classes were performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an initial chiropractic evaluation (99203) provided on September 6, 2019.
You asked the Plan to pay for the evaluation. You say that the evaluation is necessary before any provider renders services. The Plan denied your request. The Plan says the initial evaluation provided by a chiropractor is not a covered benefit.
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. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an initial chiropractic evaluation (99203) provided on September 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI of the lumbar spine (72148) provided on July 12, 2019 through July 15, 2019.
You asked the Plan to pay for the MRI. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an itemized bill was not received within the appropriate time frame.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. You have not submitted sufficient information to determine whether payment is due. Therefore, we decided that the Plan does not have to pay for an MRI of the lumbar spine (72148) provided on July 12, 2019 through July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit and ECG provided on August 7, 2019.
You asked the Plan to waive the copayments for the office visit and ECG. You say that the EKG and office visit were routine. The Plan denied your request. The Plan says the copayments 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 a $20 copayment for each office visit and a $10 copayment for x-rays, laboratory and other diagnostic tests. You have been asked to pay a $20 copayment for the office visit and a $10 copayment for the ECG. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you were treated for hypertension and hyperlipidemia during the office 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 copayments for the office visit and ECG provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code S0077 provided on September 18, 2019.You asked the Plan to pay forCPT code S0077. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT code S0077 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.Therefore, we decided that the Plan does not have to pay forCPT code S0077 provided on September 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to be provided by a provider outside of your medical group.You asked the Plan to pre-approvean office visit to be provided by a provider outside of your medical group. You say that you have previously seen this doctor.The Plan denied your request. The Plan says this service is available within your Medical Group.Medicare rules say that plans can require enrollees to get care from networkproviders. The contract with the Plan says that you may be required to receive services from within your Medical Group.The requested provider in this case is not a network provider with your Medical Group. The Plan has providers within your Medical Group available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean office visit to be provided by a provider outside of your medical group.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo tablets 2MG.You asked the Plan to pre-approveLivalo tablets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Livalo tablets are not covered under the enrollee's Medicare Part B benefit. The plan states they believe the enrollee's pharmacy benefit manager is Express Scripts.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-approveLivalo tablets 2MG.Benefits for Livalo tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D brush biopsy testing provided to the enrollee on July 15, 2019.
You asked the Plan to pay for the testing. You say that all of the laboratory procedures are not investigational. The Plan denied your request. The Plan says experimental procedures are not covered under the enrollee's plan.
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 testing. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found the documentation does not show that the additional testing was medically necessary or reasonable to diagnose, treat or otherwise manage the enrollee's condition. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D brush biopsy testing provided to the enrollee on July 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a carotid stent (CPT 37215).
You asked the Plan to pre-approve the carotid stent. You say that the records provided support the need for the requested carotid stent. The Plan denied your request. The Plan says a carotid stent is not medically necessary because the clinical information does not indicate that the enrollee has symptomatic carotid artery stenosis that is 70% or greater.
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 carotid stent. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has an asymptomatic carotid stenosis. In this circumstance there is no documented high risk features that would preclude safe treatment with surgical carotid endarterectomy as opposed to carotid stent placement. Specifically there is no documentation of congestive heart failure, left ventricular ejection fraction less than 30%, unstable angina, recent myocardial infarction, previous carotid endarterectomy with recurrent stenosis or prior neck radiation. 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 carotid stent have not been met. Therefore, we decided that the Plan does not have to pre-approve a carotid stent (CPT 37215).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay foranabolic steroids provided to the enrollee on December 21, 2018.You asked the Planto pay forthe steroids. You say that this should be paid for.The Plandenied your request. The Plansaysthis code is a statutory exclusion.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 80327 is "Anabolic steroids; 1 or 2."We find that CPT code 80327 is not supported in the medical record. Specifically, this code has a status indicator of X. This indicates that the code is a statutory exclusion. Based on this information, we decided that Medicare rules for coverage of the steroids have not been met.Therefore, we decided that the Plandoes not haveto pay foranabolic steroids provided to the enrollee on December 21, 2018