Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was alert with confusion, and tolerated a regular diet. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was independent with mobility and required minimal assist with functional mobility, including gait to 150 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 2, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because the doctor did not do anything. 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 $40 copayment per visit for a specialist office visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a follow-up visit and there was a physical examination.
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 specialist office visit provided on February 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on December 30, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on December 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 7, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you were transferred from the emergency room and admitted to a different hospital. 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 $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were admitted to a different hospital than the hospital for the emergency room 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 emergency room visit provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0642) provided to the enrollee on August 29, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0642) provided to the enrollee on August 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOPDIVO for the enrollee.You asked the Plan to pre-approveOPDIVO. The Plan denied your request. The Plan says that documentation does not indicate the patient has tried systemic chemotherapy or has a contraindication for chemotherapy.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 OPDIVO. Our reviewer says that OPDIVO is not medically reasonable and necessary for the enrollee in this case. OPDIVO is being requested for treatment of squamous cell lung cancer that recurred after surgery and radiation. Surgery and radiation are only treatment noted in the documents submitted for review. The prescriber offered the option of multi agent chemotherapy. The documentation states the enrollee refuses chemotherapy due to potential side effects. The documentation does not support that OPDIVO is safe and effective for the enrollee. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of OPDIVO.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OPDIVO have not been met.Therefore, we decided that the Plan does not have to pre-approveOPDIVO for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the four gingival irrigations and application of desensitizing resin for cervical and/or root surface provided on December 13, 2019.
You asked the Plan to pay for the four gingival irrigations and application of desensitizing resin. The Plan denied your request. The Plan says that gingival irrigation and application of desensitizing resin for cervical and/or root surface are not covered benefits.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 did not provide a copy of the applicable 2019 Evidence of Coverage for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Thus, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the four gingival irrigations and application of desensitizing resin for cervical and/or root surface provided on December 13, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9500 provided from December 27, 2019 to December 31, 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 S9500 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; 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 S9500 is not supported in the medical record. Specifically, code S9500 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 for the home infusion therapy services coded S9500 provided from December 27, 2019 to December 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from November 8, 2019 to December 7, 2019.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the member's condition did not required daily skilled services at an inpatient skilled nursing facility level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from November 8, 2019 to December 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea laminectomy and spinal neurostimulator for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this test is helpful for evaluation of the enrollee's health problem.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee has had cervical surgery and neck pain. This device is experimental for neck pain. It should not be approved.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 Plandoes not haveto pre-approvea laminectomy and spinal neurostimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve creation of eye fluid drainage tracts using laser. You asked the Plan to pre-approve the procedure. You say that this is medically necessary.The Plan denied your request. The Plan says that this procedure is needed when the presence of narrow angles is confirmed by goniscopy.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will becovered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found laser peripheral iridotomy was indicated and medically necessary in this case based on the medical records. According to the examination notes and findings, the patient did undergo gonioscopy examination that revealed narrow angles in both eyes. Due to the clinical concern for angle closure, it would be reasonable to proceed with the iridotomy laser. Although the initial documentation did not show that the patient had undergone gonioscopy, upon subsequent review of additional documentation, gonioscopy was indeed 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 procedure have been met.Therefore, we decided that the Plan has to pre-approve creation of eye fluid drainage tracts using laser.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology rendered on January 23, 2020.
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 are not separately payable.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities. We looked at the file and Medicare rules. The file shows that procedure code 88305 was billed with procedure code 26 for the PC, and the PC and TC were not performed in different payment localities. 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 surgical pathology rendered on January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transportation services provided to the enrollee on August 24, 2019.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says the enrollee's condition was not such that any other form of transportation was medically contraindicated.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. The file shows that ambulance services were provided from the hospital to the enrollee's residence. 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 ambulance services. Our physician reviewer found that the enrollee was evaluated in the emergency department following a mechanical fall. He sustained a contusion above his left eye. Following evaluation, he was discharged to home. Emergency medicine services documentation states the enrollee did not feel comfortable riding home with husband and requested an ambulance. Vital signs were stable and his examination was non-concerning. There was no supporting documentation of care requirements necessitating ambulance transport. The enrollee could have safely been transported for hospital evaluation by other means.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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay forthe ambulance transportation services provided to the enrollee on August 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter mitral valve procedure for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the procedure is experimental and investigational.
The Plan follows Medicare rules. Medicare rules say that Transcatheter Mitral Valve Repair is only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has a history of hyperlipidemia, hypertension, hypothyroidism, stroke, esophageal reflux, pulmonary hypertension and tissue mitral valve replacement. She now presents with dyspnea and found to have severe prosthetic mitral valve regurgitation.
Based on the records, the enrollee has symptomatic severe bioprosthetic mitral regurgitation. In this setting surgical mitral valve replacement is the standard of care unless surgical risk is prohibitively high. The records support increased surgical risk, but do not quantify risk and do not document that surgical risk is prohibitively high. In fact, surgical mitral valve replacement was reported to be discussed as an option. Coverage criteria are not met since the determination of prohibitive surgical risk is not documented. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter mitral valve procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for surgical services provided on June 7, 2019.
You asked the Plan to pay for the surgical services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the original decision to deny payment was correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 not forwarded sufficient information to determine the reason for denial. Because we cannot determine the reason for denial, we are unable to confirm if the denial of payment is correct. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. Therefore, we decided that the Plan has to pay for surgical services provided on June 7, 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 vertebral augmentation procedure.
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that vertebral augmentation is covered when the above criteria are met. 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 procedure. Our reviewer says that the requested vertebral augmentation procedure is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 78-year-old man with low back pain. He had previously undergone 4 lumbar spine surgeries. A lumbar MRI on February 29, 2020, demonstrated a compression deformity at T12 with fracture lines and marrow edema suggesting acute to subacute injury. The documentation does not support that the LCD criteria have been met in this case, as the inclusion criterion of an acute osteoporotic vertebral compression fracture less than 6 weeks old, with an MRI within 30 days has not been met. In addition, there are other abnormalities noted which may be contributing to the enrollee's back pain, such as interval progression of degenerative disk disease with foraminal stenosis. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a vertebral augmentation procedure.