Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) for enrollee.You asked the Plan to pre-approve these services. You say that the enrollee needs treatment.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that TMS is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of severe recurrent major depressive disorder. She has tried Lexapro, Cymbalta, Zoloft and Effexor, each of which showed side effect. She most show 50 percent improvement on prior treatment with a pre-and post-score on the Personal Health Questionnaire Depression Scale (PHQ-9). The records do not support that these criteria are met; therefore, TMS 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 transcranial magnetic stimulation (TMS) for enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 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 they are 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 thisphysician'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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair upgraded electronics.You asked the Plan to pre-approvethe power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the electronics are medically necessary for controlling the power seating features.The Plan denied your request. The Plan says there is no medical need to control the requested power options through the joystick.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. Documentation shows that the enrollee has normal range of motion and 5/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe power wheelchair upgraded electronics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient care provided to the enrollee from June 6, 2019 to June 28, 2019.You asked the Plan to pay forthis claim. You say that this inpatient care should be covered by the Plan.The Plan denied your request. The Plan says they exhausted their timeframe to review this appeal.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare requires providers to submit medical records to substantiate the services billed. There were no medical records submitted to support the services billed. Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay forinpatient care provided to the enrollee from June 6, 2019 to June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for INR monitoring services provided to the enrollee from July 29, 2019 to August 19, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this was not billed correctly.The Plan must follow Medicare rules. The rules say that one unit of HCPCS G0249 is equivalent to four tests. The rules also say that self-testing of PT/INR should not occur more frequently that once a week. Additionally, Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the definitionof HCPCS code G0249 is "Provision of test materials and equipment for home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision ofmaterials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests."We find that HCPCS code G0249 is not supported in the medical record. Specifically, these services are being billed once per week -on July 29, 2019, August 5, 2019, August 12, 2019, and August 19, 2019. Each billing of HCPCS G0249 is for four tests. This means that 4 tests are being billed for each week, which exceeds the limits set by Medicare. 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 forINR monitoring services provided to the enrollee from July 29, 2019 to August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 10, 2019 and
billed under codes 80307 and G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do not contain a valid physician order and specific documentation
regarding the necessity of this testing.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of
testing. The physicians order must be appropriately signed, and the medical records must specifically show
how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed
to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria
are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee.
Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on June 10,
2019 and billed under codes 80307 and G0483.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 7, 2019 with a femur fracture and underwent surgical repair. She is walking 30 to 50 feet with minimum assistance and a rolling walker. She needs minimum assistance with transfers, toileting, bathing, grooming, and dressing. She has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from additional therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the Enrollee on April 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the Enrollee on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe physician 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 neither emergent nor urgent to seek out-of-network care. The Plan states you have been approved for surgery with an in-network provider, on March 17, 2020. The Plan states that there are other in-network specialists available to you that can provide the services you are requesting, 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 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-approvethe physician services to be provided by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from June 9, 2019 through June 30, 2019.
You asked the Plan to pay for SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member required oversight of his medical conditions and medication management. He was at risk for secondary complications of immobility such as pressure ulcers and contractures. He had cognitive impairment and would not be expected to be able to self-monitor or administer insulin for his diabetes. There were no identified ongoing skilled therapy needs. Skilled services as of the date in question were not medically necessary or reasonable. A periodic reassessment of his condition would be expected to determine the potential for measurable gains within a reasonable and predictable period of time. There were skilled needs, but they did not need to be provided on a daily basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from June 9, 2019 through June 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alarm device (A9280).
You asked the Plan to pre-approve the alarm device. You say that the alarm device is medically necessary and would help you to continue to live independently. The Plan denied your request. The Plan says this device is not covered by Medicare or your health plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the alarm device (A9280).
Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to pay for hyperbaric oxygen therapy (G0277). We decided that the Plan does not have to pay for ambulance oxygen services (A0422).
You asked the Plan to pay for hyperbaric oxygen therapy (G0277). You say that the records provided support the necessity of the services in dispute. The Plan says that prior authorization required but not obtained.
We decided that the Plan has to pay for hyperbaric oxygen therapy (G0277).
The Plan follows Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health.
This enrollee was receiving emergency treatment for carbon monoxide poisoning. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for hyperbaric oxygen therapy (G0277).
We also decided that the Plan does not have to pay for ambulance oxygen services (A0422).
The rules say that Medicare covered ambulance services are paid based on the Medicare ambulance fee schedule. Our decision regarding code A0422 means that the Plan is not required to pay for this service because payment under the fee schedule is payment in full for the transportation. Medicare may not allow the provider to balance bill you for this code. If you are billed for more than your plan cost-sharing, you may wish to contact your plan directly to report this issue Therefore, we decided that the Plan does not have to pay for ambulance oxygen services (A0422).
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 lab services provided to the enrollee on July 8, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan stated an on-site visit was made to verify the provider's location. The Plan discovered the
provider did not operate out of the location provided on the claims as being the service address. The Plan has
advised the Provider that claims will not be paid due to this discrepancy. To date the provider has not
complied with any of the Plan's requests for clarification
The Plan must follow Medicare rules. Medicare rules state that all clinical laboratories must be properly
certified to receive Medicare payments. All reported address information and service locations must be valid
for claim payment. In this case, the service address provided cannot be verified as a valid address per the
requirements of the Medicare guidelines. Medicare rules for coverage of this claim have not been met.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 8,
2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 5, 2019 to August 31, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not show any need for therapy or any special nursing needs. The Plan also says the enrollee only received custodial 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 5, 2019 to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided from October
8, 2019 through October 31, 2019.
You asked the Plan to waive the copayment for radiation treatment. You say that you were not aware the
copayment was per treatment. You say that you should only owe $60. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $60 copayment for in-network radiation therapy.
The enrollee has been asked to pay a total of $1,080 for radiation treatment. ($60/visit x 18 visits = $1,080).
Radiation treatment falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for radiation treatment provided
from October 8, 2019 through October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing care (99308) provided on July 26, 2019.You asked the Plan to pay for the subsequent nursing care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include medical records or sufficient information to make a clinical determination.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing care have not been met. Specifically, the submitted medical record is for an incorrect date of service. The record indicates that the Plan requested the appropriate medical records. Therefore, we decided that the Plan does not have to pay for subsequent nursing care (99308) provided on July 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one hundred additional routine transportation trips (A0120).You asked the Plan to pre-approve one hundred additional routine transportation trips. You say that the requested additional transportation is necessary.The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of one hundred additional routine transportation trips.Therefore, we decided that the Plan does not have to pre-approve one hundred additional routine transportation trips (A0120).