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. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested 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 the enrollee is currently undergoing treatment at an acute care hospital for pneumonia
and suspected CoViD-19 infection, though multiple tests have been negative. The enrollee was not
intubated/ventilated and subsequently received a tracheotomy. The enrollee developed renal failure and was
started on hemodialysis. The enrollee shows signs of improvement and is tolerating the initial stages of
ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and acute care hospitals 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.
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 waive the copayment for inpatient hospital care from December 4,
2019 through December 7, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received due to the quality of care. The Plan denied your request.
The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on December 4, 2019 and discharged on December 7, 2019.
You were asked to pay a $260 copayment per day from December 4, 2019 through December 6, 2019, days 1-3
of your inpatient hospital care. You were discharged on December 7, 2019 and there was no copayment charge
for the day of discharge. Per your contract there is a $260 copayment per day required for days 1-7. 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 inpatient hospital care from December 4, 2019 through December 7,
2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the FreeStyle Libre continuous glucose monitor and supply allowance provided on August 23, 2019. You asked the Plan to pay for the continuous glucose monitor (K0554) and supply allowance (K0553). You say that the physician order and proof of delivery is correct. The Plan denied your request. The Plan says that the medical records were altered and the delivery ticket does not meet the criteria. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record contains a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the FreeStyle Libre continuous glucose monitor and supply allowance provided on August 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for computerized database analysis of multiple cycles of
digitized cardiac electrical data from two or more ECG leads represented by CPT code 0206T and billed for
date of service September 11, 2019.
You asked the Plan to pay for CPT code 0206T. You say that the medical records provided support that the
CPT code in dispute should be reprocessed for payment. The Plan denied your request. The Plan says the
facility has billed a not medically necessary Category III code.
The Plan must follow Medicare rules. Medicare rules say that, in order to be covered and reimbursed, an item
or service must meet several requirements. It must fall within a defined benefit category, it cannot be excluded
from coverage, either by statute or policy, and it must be medically reasonable and necessary. In the absence of
a National Coverage Determination (NCD), discretion may be used to establish medical policy, currently
known as LCDs and LCAs. The purpose of these LCDs and LCAs is to create a working list of services and
procedures that have been evaluated by the Medical Policy staff, and determined to not meet the reasonable and
necessary criteria as defined in Section 1862 (a)(1)(A) of the Social Security Act. LCDs and LCAs are based
on the strongest evidence available. The Medicare contractor has provided a list of services that it does not
deem medically reasonable and necessary. CPT code 0206T is present on that list.
We looked at the file and Medicare rules.vThe contractor responsible for
Medicare coverage has determined that the services represented by CPT code
0206T do not meet the criteria to be considered medically reasonable and necessary. Based on this, we found
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay
for computerized database analysis of multiple cycles of digitized cardiac electrical data from two or more
ECG leads represented by CPT code 0206T and billed for date of service September 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 26, 2019 to October 9, 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 clinically the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) 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 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 September 26, 2019 to October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram (77067, 77063) provided January 29, 2020.
You asked the Plan to pay for the mammogram. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim is a duplicate.
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 codes 77067 & 77063 are not supported in the medical record. Specifically, the record shows
the claim is a duplicate of a previous claim. Based on this information, we decided that Medicare rules for
coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a
mammogram (77067, 77063) provided January 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on September 12, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $325 copayment for nuclear medicine services at an outpatient hospital.
Review of the file shows that you received chemodenervation services at an outpatient hospital on September 12, 2019. You have been asked to pay a $325 copayment for these services. These services fall within the nuclear medicine services at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the services provided to the enrollee from August 17, 2019 through September 16, 2019.You asked the Plan to waive the cost-share forthe services. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.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 did not meet her out-of-pocket maximum until September 25, 2019. The claims on dates of service August 17, 2019 through August 27, 2019 and September 16, 2019 copayments and coinsurance would not be covered at 100%. 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 cost-share for the services provided to the enrollee from August 17, 2019 through September 16, 2019
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. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 you required total assistance with bed mobility. You are non-ambulatory as baseline. The documentation does not support that you require the intensive of services provided at an IRF. You are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450) provided November 27, 2019.
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied your request. The Plan says the service billed shares a bundled relationship with another code billed.
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, we have confirmed that code the 70450 shares a column I / column II relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450) provided November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 18, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you would have never used this dentist if you had not been cleared from the Plan. The Plan denied your request. The Plan says the services received are covered benefits; however they are only covered when received from an in-network provider.
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. The provider is not in-network and your EOC clearly states, Exclusions and Limitations: Services performed by an out-of-network dentist if your plan does not have out-of-network coverage. Therefore, we decided that the Plan does not have to pay for the dental services provided on December 18, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of omalizumab beneath the skin or into muscle
for therapy, diagnosis, or prevention (96372, J2357) provided on July 16, 2019 by an out of network (OON)
provider.
You asked the Plan to pay for an injection of omalizumab beneath the skin or into muscle for therapy,
diagnosis, or prevention. You say that a prior authorization request was attempted a
representative stated that no prior authorization was required for this service. The Plan denied your request.
The Plan says this is a non-network provider with the member's health plan, and 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 an injection of omalizumab beneath the skin or
into muscle for therapy, diagnosis, or prevention (96372, J2357) provided on July 16, 2019 by an out of
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levemir FlexTouch injections.
You asked the Plan to pre-approve Levemir FlexTouch. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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-approve Levemir FlexTouch
injections.
Benefits for Levemir FlexTouch may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323). You asked the Plan to pre-approve Euflexxa. You say that the Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before Euflexxa can be considered. 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 Euflexxa. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee has not had a trial of the plan preferred drugs and the record does not show any reason why they would be contraindicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital admission for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be provided without an inpatient stay after the surgical procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is to undergo a procedure that is not on the inpatient only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities pre-operatively, which would clearly necessitate a prolonged (i.e. two midnight) stay. The enrollee should present for, undergo and be monitored following the procedure as an outpatient. Should complications arise during or after the procedure that warrant a prolonged stay, the enrollee can be converted to inpatient status, at that time, under the two midnight rule. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital admission for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from
November 1, 2019 through November 9, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan
denied your request. The Plan says there was no medical documentation submitted and the Plan made three
calls to obtain the needed information.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of inpatient hospital care have not been met. No notes from the doctor
have been sent showing why the enrollee needed this admission. Per Medicare rules, the doctor would need to
send medical records showing : -What medical problems the enrollee was having -What the enrollee's blood
work and imaging (like x-rays or CT) showed -What treatment and medication the enrollee needed. Therefore,
we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from
November 1, 2019 through November 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy.
You asked the Plan to pre-approve occupational therapy. 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 occupational therapy. 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 the enrollee has a history of a cerebral infarction, gait abnormality and disequilibrium. While occupational therapy is generally accepted as specific and effective therapy for the enrollee's condition, the enrollee was approved for 40 visits and has already been receiving treatments. Additional visits are not justified based on the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional occupational therapy.