Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10additional physical therapy services.You asked the Plan to pre-approve additional physical therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had at least 10 prior therapy visits. The documentation shows improvement in your Oswestry score for your low back but continues to reveal that you have a score of 32 and unable to perform usual activities. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide ongoing treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. Your therapy needs should be able to transition to home exercises. Therefore, you do not meet criteria for the requested physical therapy 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 additional physical therapy services have not been met.Therefore, we decided that the Plan does not have to pre-approve10 additional physical therapy services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 17, 2019 through August 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 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 medical records provided indicate that the admitting physician expected the enrollee's admission to 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 August 17, 2019 through August 20, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve boost, a high protein oral liquid (B4160).
You asked the Plan to pre-approve this nutritional supplement. You say that this oral supplement is medically necessary to promote optimal health for the enrollee. The Plan denied your request. The Plan says that orally administered nutritional products are not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The item you asked the Plan to pre-approve is an oral nutritional supplement. Therefore, we decided that the Plan does not have to pre-approve boost, a high protein oral liquid (B4160).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided on October 30, 2019.You asked the Plan to pay forinpatient care. You say that this should be paid.The Plan denied your request. The Plan says payment for these services is the responsibility of Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for inpatient care provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory tests provided on February 4, 2019.
You asked the Plan to pay for the laboratory tests. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory tests provided on February 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on October 29, 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 procedure code G0500 is not supported.
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 G0500 is moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate). We find that CPT code G0500 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status. 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 moderate sedation services rendered on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided from November 28, 2018 to July 22, 2019.You asked the Plan to pay forthe dental services. You say that these services are related to your diagnosis of Advanced Periodontal Disease and the recommended treatment plan. You also say that you see no reason why the costs for these necessary services were denied.The Plan denied your request. The Plan says you had already received the maximum amount of coverage allowed for these services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the 2018 Plan offered a $250 allowance every year for non-Medicare covered preventive dental services. You are responsible for any amountabove the dental coverage limit. The record shows that you met the annual maximum benefits on November 28, 2018, and your annual maximum benefit for 2018 had been exhausted. The 2019 Plan offered a $525 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on April 23, 2019 and your annual maximum benefit for 2019 had been exhausted.Therefore,we decided that the Plan does not have to pay forthe dental services provided from November 28, 2018 to July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided from April 2, 2019 through April 5, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records did not contain a critical care note of 30-74 minutes for dates of service from April 2, 2019 through April 5, 2019. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided from April 2, 2019 through April 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on August 16, 2019.
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is incident to the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 93010 is not supported in the record. Specifically, payment for this service is included in the payment for the primary procedure. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on October 11, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you are appealing the denied claim because the notes support the need for services.The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services for are non-participating providers. The services are not considered urgent/emergent in nature. There is no referring provider listed. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 foran office visit (99214) provided on October 11, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy. 
 
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial of Retacrit. The documentation does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150 x 2), prophylaxis (D1110 x 2), and the complete series of periapical x-rays (D0210) provided from January 14, 2019 to July 16, 2019.You asked the Plan to pay forthe dental services. You say that you were misinformed by the provider's participating status.The Plan denied your request. The Plan says coverage is available from providers only. The Plan also says that the provider in this case is not participating with the Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not covered because you received them out of network.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150 x 2), prophylaxis (D1110 x 2), and the complete series of periapical x-rays (D0210) provided from January 14, 2019 to July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.You asked the Plan to pre-approve the physician's services. You say that you have been working with this physician for over thirty years andhe has seen you through a lot. You say that your current PCP is not a good fit. The Plan denied your request. The Plan says you may not opt to use your POS benefits while in the plan's service area.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 care that cannot be provided by network providers.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 services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), collection of venous blood by venipuncture (36415), magnetic resonance imaging (an MRI) (74183), a blood test (80053), an alpha-fetoprotein level check (82105), a complete blood count (CBC) (85027), and an injection of gadoterate meglumine (A9575), provided on July 22, 2019 by an out of network provider.
You asked the Plan to pay for a hospital outpatient clinic visit. You say that services were medically necessary due to the patient's symptoms of right upper quadrant abdominal pain with nausea and vomiting. You are asking for a review of the medical records and to reprocess the claim for payment. The Plan denied your request. The Plan says the provider is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services. The member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a hospital outpatient clinic visit (G0463), collection of venous blood by venipuncture (36415), magnetic resonance imaging (an MRI) (74183), a blood test (80053), an alpha-fetoprotein level check (82105), a complete blood count (CBC) (85027), and an injection of gadoterate meglumine (A9575), provided on July 22, 2019 by out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forlaboratory testing provided on June 6, 2019.You asked the Plan to pay forlab tests. You say that these tests were ordered by the enrollee's in-network treating physician to provide information to adjust the enrollee's treatment plan.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these tests were not medically necessary according to Medicare guidelines.The Plan must follow Medicare rules. The rules say that Medicare health plans must makereasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has notspecified whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these tests would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of these tests. Therefore, the Plan has not shown that their decision to deny payment for these services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay forlaboratory testing provided on June 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 10, 2019 through December 11, 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 December 10, 2019 through December 11, 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 a percutaneous left atrial appendage closure (LAAC), also known as the Watchman procedure (33340).You asked the Plan to pre-approve the Watchman procedure. You say that the requested Watchman procedure is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Watchman procedure.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 Watchman procedure. Our reviewer says that the enrollee does not meet criteria for the requested Watchman procedure. Our physician reviewer found based on the records the enrollee has atrial fibrillation treated with Xarelto with no documented significant bleeding complications. In this circumstance coverage criteria for placement of a Watchman device are not met since one criteria includes "patient deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making". The documentation does not support the enrollee is unable to take long term anticoagulation. 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 Watchman procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve a percutaneous left atrial appendage closure (LAAC), also known as the Watchman procedure (33340).