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

We decided that the Plan does not have to pre-approve a SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is close to his baseline level of functioning.
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 SNF services. Our physician reviewer found that the enrollee continues to receive wound care. He has pain which needs to be assessed and treated. The enrollee requires oversight of his medical conditions and medication management. He is at risk for secondary complications of immobility such as further pressure ulcers and contractures. The enrollee is at a dependent level of function for bed mobility and transfers. He reported pain all over and was yelling out with all mobility and range of motion. He had limited range of motion of all extremities with limited active movement of the upper extremities. He requires either physical therapy or occupational therapy for mobility and for range of motion and assessing his wheelchair and positioning needs. There are skilled needs, but they do not need to be provided on a daily basis. The enrollee's condition would not be expected to deteriorate with services provided on a less than 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of denosumab (Prolia).
You asked the Plan to pre-approve Prolia. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Prolia is not accepted for use for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for Prolia. Our physician reviewer found the Food and Drug Administration (FDA) approved Prolia as a treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for non-metastatic prostate cancer. The records indicate that the enrollee is not at high risk for fracture. The enrollee also has metastatic prostate cancer and Prolia has not been approved for this category for enrollees. The use of Prolia for this enrollee is not supported by Medicare drug compendia or by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of denosumab (Prolia).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 1, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you don't recall having to pay for bloodwork before. 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 $15 copayment for Medicare-covered lab services. You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 16, 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 says the enrollee did not have prior authorization for out of network care.
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 physician services provided to the enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a speech, language, voice, communication, and/or auditory processing disorder (92507x2) and the treatment of swallowing dysfunction and/or oral function for feeding (92526x2).
You asked the Plan to pay for the treatment of a speech disorder and swallowing dysfunction. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not document the services at issue.
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 92507 is treatment of speech, language, voice, communication, and/or auditory processing disorder; individual. The CPT Code Manual definition of 92526 is treatment of swallowing dysfunction and/or oral function for feeding. We asked our coder 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 treatment of a speech disorder and swallowing dysfunction. Our reviewer says that CPT codes 92507x2 and 92526x2 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided for August 26, 2019 and
August 27, 2019 do not include documentation of Treatment of swallowing dysfunction and/or oral function for feeding or Treatment of speech, language, voice, communication, and/or auditory processing disorder being provided. The documentation is illegible. Therefore, these services cannot be validated for August 26, 2019 and August 27, 2019. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the treatment of a speech disorder and swallowing dysfunction have not been met. Therefore, we decided that the Plan does not have to pay for the treatment of a speech, language, voice, communication, and/or auditory processing disorder (92507x2) and the treatment of swallowing dysfunction and/or oral function for feeding (92526x2).
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 enrollee can receive the care required at the current facility they are in. Therefore, coverage criteria has not been met.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 (ACH) following heart valve surgery. On February 3, the enrollee underwent a video-assisted thoracoscopic surgery (VATS) procedure with a preemptive tracheotomy. There is insufficient documentation since that time to show that the enrollee is stable enough for (i.e. no post-operative complications) or in need of (i.e. has failed weaning) LTACH services. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper airway stimulation device (0466T and 64568).
You asked the Plan to pre-approve an upper airway stimulation device. You say that the services are necessary. The Plan denied your request. The Plan says the procedure is not a covered service. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Category III CPT code 0466T is considered not medically necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an upper airway stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper airway stimulation device (0466T and 64568).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on July 29, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 and the ordering physician are not network providers with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a drug test provided on July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latuda for the enrollee.
You asked the Plan to pre-approve Latuda. You say that the enrollee has been stable on this medication. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Latuda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 3, 2018
through April 4, 2018.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found based on the documentation prior to admission, there was no definite evidence of a
surgical fracture to warrant admission. Although awaiting computed tomography (CT) is reasonable, this could
have been completed under observation status until completed, and only conservative care was recommended.
Therefore, based on the records, the physician did not reasonably expect the patient to require at least a two
midnight stay in the hospital.
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 from April 3, 2018 through April 4,
2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 17 to April
18, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says services could have been provided at a lower level of care.
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 review has determined that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient'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 April 17 to April 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were visiting your son when your
sugar levels dropped and you went into insulin shock. Your wife and son called for the ambulance which came
and treated you. You say the Plan should cover the services. The Plan denied your request. The Plan says these
services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on July 20, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full length semi-rigid arch support 
 
You asked the Plan to pre-approve foot orthotics. You say that you have had these orthotics before and they no longer work because both of your knees were replaced. You say that you were also born with Pes Cavus. You say that, due to your age, this has caused significant rigidity in your ankles. You say that walking is very difficult for you. You say that the orthotics are critical to assist you in going forward, as evidenced by the doctor's request. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a full length semi-rigid arch support
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 June 9, 2019 through June 13, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our physician reviewer found the treating physician noted that the patient was stable for transfer following the initial examination and computed tomography (CT) results were available on June 9, 2019. Vitals were stable, blood work and imaging did not reveal any indication of imminent danger if she were to be transferred. Based on the documentation, the patient was stable and recommended for transfer on June 9, 2019, 8:40 pm. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 9, 2019 through June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home monitoring/testing supplies (G0249) provided on January 19, 2019 through January 24, 2019.
You asked the Plan to pay for the home monitoring/testing supplies. You say that the member is significantly benefiting monetarily by weekly home testing services and the Plan's edits are not in compliance with federal regulations. The Plan denied your request. The Plan says payment cannot be processed for procedure code G0249 as services billed earlier than 25 days.
The Plan must follow Medicare rules. Medicare rules say that that self-testing with the device should not occur more frequently than once a week. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home monitoring/testing supplies have not been met. Specifically, 12 units of G0249 have been billed within a 3-week period. This exceeds the Medicare frequency allowance. Therefore, we decided that the Plan does not have to pay for home monitoring/testing supplies (G0249) provided on January 19, 2019 through January 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 17, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly. have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the annual wellness visit provided on August 23, 2019.
You asked the Plan to waive the copayment for the annual wellness visit. You say that you were told there would be no charge. You say this is a large bill for what little was done. 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 50% for of the Medicare-allowed amount for the out-of-network Medicare-covered annual wellness visit. You have been asked to pay $81.79 which is 50% of the allowed amount for the annual wellness visit. The allowed amount is $163.58. ($163.58 x 50% = $81.79). The annual wellness visit falls within the "Annual wellness visit" benefit category. The record shows you received services.
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 annual wellness visit provided on August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a Transcatheter mitral valve repair (TMVR) provided October 12 to October 14, 2017
You asked the Plan to pay for the TMVR. You say that the service was not part of a clinical trial. The Plan denied your request. The Plan says this service is only covered when part of a clinical trial.
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 the TVMR is not supported by the records submitted. Specifically, CMS issued a Medicare National Coverage Determination which allows for coverage of TMVR under Coverage with Evidence Development (CED) with certain conditions. A valid clinical trial number was not applied on the submitted claim. This means the service was billed outside of CED. Based on this information, we decided that Medicare rules for coverage of the TMVR have not been met. Therefore, we decided that the Plan does not have to pay for a Transcatheter mitral valve repair (TMVR) provided October 12 to October 14, 2017