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

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity (73721).You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that rules for coverage were not met. Our physician reviewer found the reviewed documents do not include previous imaging results, previous consultation notes, differential diagnosis or plan of care.  Without the supporting documentation, medical necessity cannot be determined.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity (73721).
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 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 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for dysphagia requiring surgery and supplemental nutrition. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.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 pay for the acute inpatient hospital care provided July 10 -July 11, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the level of care in dispute.The Plan denied your request. The Plan says the enrollee was discharged after a one midnight hospitalization. The Plan says that an observation level of care was reasonable and 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on July 10, 2019 from her primary care physician's office with dizziness, weakness and a HCT of 21. In the emergency department the enrollee's vital signs were stable and her physical exam was unremarkable, including a negative FOBT. She was treated with IV fluids and was transfused with packed RBCs. She was admitted; her condition stabilized and improved and she was discharged home on July 11,2019 with outpatient follow-up. The record did not show that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided July 10 -July 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on April 28, 2018.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance services was not filed until December 9, 2019.This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for services provided on April 28, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on
February 24, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The
Plan says that the correct copayment has applied per your contract with the Plan.
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 $10
copayment for Medicare-covered lab services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory
services on February 24, 2020. You have been asked to pay a $10 copayment for the laboratory services. The
laboratory services fall within the Outpatient diagnostic tests 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 laboratory services provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and is status post lumbar laminectomy. She has SI joint pain and has tried a home exercise program, chiropractic therapy, and medication trials. The requested RFA of the SI joint is considered experimental/investigational in nature due to wide variation of efficacy in peer-reviewed literature. The services are therefore not reasonable or medically necessary.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 radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 Hyalgan. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that the service is necessary. The Plan denied your request.
The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that SBRT will be considered medically reasonable and
necessary when specific criteria is 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 SBRT. Our reviewer says that the
service is not medically necessary. Our physician reviewer found while SBRT for widespread disease (which is
the case for this enrollee) can perhaps be considered in some selected enrollee, there is no plausible, compelling
reason for SBRT (over other forms of radiation) for this enrollee. It is not thought that SBRT would necessarily
be furnished outside the standard of care (as there really is none), however the coverage criteria are not met as
the entire tumor burden cannot (and is not planned) to be encompassed, but rather only one liver metastases.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on December 31, 2019.You asked the Plan to waive the copayment for the duplex scan. You say that you were not a patient at this hospital. You say that you shouldn't be responsible for the bill.The Plan denied your request. The Plan says the copayment 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 $75 copayment for diagnostic procedures and tests at an in-network outpatient hospital. You have been asked to pay a $75 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 duplex scan provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 20, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator (K0606) provided on November 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for automatic external defibrillator. You say that this enrollee is unable to obtain these services in-network as you are the sole provider and you ask for reconsideration for in-network benefits.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Prior-authorization is required for all DME prior to services being rendered.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 automatic external defibrillator (K0606) provided on November 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit on February 6, 2020.You asked the Plan to waive the copayment for the specialist office visit. You say that you do not think it is right to be charged a copayment when you only went in to get test results. 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 for each in-network specialist visit for Medicare-covered benefits. 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 a conversation about possible knee replacement and arthroscopy, including risks and benefits.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 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 92250 provided on January 28, 2020.You asked the Plan to pay for CPT code 92250. 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 as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. In this case, CPT code 92250 is a column two code and cannot be billed with column one code, 92202.Therefore, we decided that the Plan does not have to pay for CPT code 92250 provided on January 28, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the chemotherapy administration services related to the use of Keytruda provided on December 11, 2019 billed with one unit of code 96413.You asked the Plan to pay for the chemotherapy administration services as billed. You say that the documentation supports the billed services.The Plan denied your request. The Plan says that the documentation does not show a start and stop time for this treatment so payment cannot be made for it.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 96413 is Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug.We find that CPT code 96413 is supported in the medical record. Specifically, it is documented that the needle was placed at 1:58PM. It is noted that the Keytruda infusion was started at 2:15PM and that a heparin flush was performed at 3:05PM. The documentation supports that at least one hour of chemotherapy administration took place, which is what is described by the billed code. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration services as billed have been met.Therefore, we decided that the Plan has to pay for the chemotherapy administration services related to the use of Keytruda provided on December 11, 2019 billed with one unit of code 96413.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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy services for a total of 20
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 the enrollee has a diagnosis of
generalized muscle weakness, osteoarthritis of the left hip, urinary tract infection and falls. The enrollee
requires contact guard assistance with walking 440 feet with a rolling walker. The services do not need a
therapist only to be safely and effectively performed. The documentation does not support that the patient only
needs the supervision of a therapist for the additional 10 sessions of therapy without evidence of outcome of
the already authorized therapy and evaluation of any functional deficits. Therefore, the enrollee does not meet
criteria for the requested 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-approve 10 additional physical therapy services for a total of 20 services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the
requested CT services. The Plan denied your request. The Plan says the records show an approval for the same
test or one like it is on file and still in effect. The Plan says that the records do not show the results of this
study. The Plan say that the results of the approved study may show the doctor what needs to be seen in order
to treat the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 CT scan. Our reviewer says that the
requested CT scan is not medically necessary. Our physician reviewer found the enrollee has a history of
stenting in the left subclavian artery for a diagnosis of stenosis. She reports episodes of dizziness and
paresthesias of the left arm. Medical records include communication between the ordering provider and a nurse
noting the enrollee should be scheduled for a CT angiogram. The records show that the enrollee has an
approved computed tomography angiogram of the chest (CPT 72175) starting on May 11, 2020.
Documentation of this test result was not included for review. There are no records discussing the requested
test, computed tomography scan of the chest with contrast (CPT 71260). Without the support of the
documentation, medical necessity cannot be determined.
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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve computed tomography (CT) services.