Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 19, 2020, through December 22, 2020.

You asked the Plan to pay for the acute inpatient level of care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the documentation does not support that the services rendered were medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting.

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 acute inpatient level of care. Our reviewer says that the acute inpatient hospital care was medically necessary. Our physician reviewer found that the record showed that at the time of the 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 the acute inpatient level of care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 19, 2020, through
December 22, 2020.

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 pay for skilled nursing facility services provided December 1, 2020 to December 2, 2020.

You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.

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 services are not supported in the medical record. Specifically, the diagnosis code billed is for an initial encounter. The services provided were subsequent care. Based on this information, we decided that Medicare rules for coverage of the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided December 1, 2020 to December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 25, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Evencare G2 test strips.
You asked the Plan to pre-approve the Evencare G2 test strips. You say that this request is medically necessary. The Plan denied your request. The Plan says there is no evidence that the requested test strip is needed over the Plan's preferred brand.
The Plan follows Medicare rules. Medicare rules say that a Plan is allowed to specify a preferred brand as long as the conditions in the Medicare rules section are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Evencare G2 test strips. Our reviewer says that this request is not medically reasonable and necessary. Our physician reviewer found there is no reason given why the enrollee would need to use the prescribed Evencare G2 strips instead of the preferred Accu-chek strips. Without a substantive reason for requiring the requested test strips, the request will be denied as not medically reasonable and necessary as the Plan's preferred brand is available for the enrollee.
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 Evencare G2 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Evencare G2 test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not tried and failed the required drug, Zoledronic acid. Our reviewer found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also found that the enrollee has not had an osteoporosis-related fracture.

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 Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory testing provided on October 19, 2020.
You asked the Plan to waive the coinsurance for lab tests. You say that most of these tests were ordered by your general practitioner and were required for the annual physical. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 20% coinsurance for lab services. The allowed amount of this claim is $1,919.68, resulting in a coinsurance amount of $383.93. You have been asked to pay 20% coinsurance for lab tests. Lab tests 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 coinsurance for laboratory testing provided on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that the member would benefit from at least a week of physical and occupational therapy. The Plan denied your request. The Plan says that the record does not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391) for tooth # 31 provided on November 17, 2020.
You asked the Plan to pay for the dental service. You say that you were assured that these services would be covered this year. The Plan denied your request. The Plan says 1 filling is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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. Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the filling for tooth # 20 that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the filling (D2391) for tooth # 31 provided on November 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional physical therapy (PT) home health visit (G0151), and additional occupational therapy (OT) home health visit (G0152 x 2).

You asked the Plan to pre-approve the skilled services. You say that the enrollee has made great strides. You also say that the enrollee is still unable to stand by herself or get out of bed without assistance. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 skilled services. Our reviewer says that the additional skilled PT and skilled OT services not medically necessary. Our physician reviewer found the provided documentation does not support that you require additional skilled rehab services to provide treatment that is medically necessary in a predictable period of time. The reviewer found that you do not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

The reviewer also found that you should be independent with a home exercise program. Therefore, the reviewer found that the additional home health services are not 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 the skilled services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional physical therapy (PT) home health visit (G0151), and additional occupational therapy (OT) home health visit (G0152 x 2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for diagnostic mammography provided on July 20, 2020.
You asked the Plan to waive the deductible for diagnostic mammography. You say that the provider billed this incorrectly as there was nothing in the routine imaging to warrant performing a diagnostic mammogram. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible for diagnostic mammography. This testing was provided for a non-routine indication, so it is considered to be diagnostic mammography. At the time this claim was processed, $563.32 of the $750 deductible had been met. The allowed amount of this claim is $145.51, resulting in a deductible obligation of $145.51. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the time diagnostic mammography was received on July 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for diagnostic mammography provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that the requested sacroiliac joint radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac joint radiofrequency ablation is 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 sacroiliac joint radiofrequency ablation. Our reviewer says that the requested sacroiliac joint radiofrequency ablation is not medically necessary. Our physician reviewer found the enrollee has sacro-ilitis. He had diagnostic lateral sacral branch blocks with greater than 89% pain relief. The request is for RFA of the lateral sacral branches. This procedure is considered experimental/investigational due to the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable and 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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 9, 2020.

You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion imaging (78452) provided on December 29, 2020.

You asked the Plan to pay for myocardial perfusion imaging. You say that this was billed with an appropriate POS. The Plan denied your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that a provider furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. 

We looked at the file and Medicare rules. The record shows that the service at issue was provided to an inpatient but was not reported with POS 21. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pay for myocardial perfusion imaging (78452) provided on December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient cardiac catheterization
(C1769, C1894, 93458, C1887) provided August 3, 2020.

You asked the Plan to waive the copayment for the cardiac catheterization. You say that only the $50
diagnostic test copayment should be applied. The Plan denied your request. The Plan says the correct
copayment was applied.

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 $475
copayment for outpatient hospital services.

You have been asked to pay a $475 copayment for the cardiac catheterization. The cardiac catheterization falls
within the outpatient hospital services 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
an outpatient cardiac catheterization (C1769, C1894, 93458, C1887) provided August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for congestive heart failure. The enrollee does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the medical record supports a need for physical and/or occupational therapy, there is no
documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
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 Euflexxa injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia, Euflexxa is not supported. The records show an x-ray revealed an unremarkable right knee. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on July 22, 2020.

You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says there was no proof of delivery.

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 does not contain a valid proof of delivery to support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on July 22, 2020.