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

We decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the cervical spine.You asked the Plan to pre-approvethe MRI. You say that the documentation provided supports the medical necessity to justify certification.The Plan denied your request. The Plan says that the records do not show the results of x-rays of the spine which would explain the need for further imaging or showing that the x-rays failed to find the source of the problem.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 the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has chronic severe neck pain with radiation down her Left arm after a slip and fall on November 24, 2020. The paininterferes with her sleep. She is taking Oxycodone and Tizanidine for pain. Her physical exam shows markedly decreased range of motion, changes in motor strength and sensation as well as several positive physical exam findings.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 been met.Therefore, we decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the cervical spine.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 toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe 60mg Morphine Sulfate tablets.You asked the Plan to pre-approvethe Morphine Sulfate tablets. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered for the member's condition under Medicare Part B.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-approvethe 60mg Morphine Sulfate tablets.Benefits for the Morphine Sulfate tabletsmay be available under Medicare Part D.Contactthe 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-approveRepatha SureClick 140mg/ml.You asked the Plan to pre-approveRepatha SureClick. You say that Repathais medically necessary.The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B Medical Benefit.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-approveRepatha SureClick 140mg/ml.Benefits for Repatha SureClickmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvePaclitaxel, Dexamethasone Sodium Phosphate and Palonosetron.You asked the Plan to pre-approvethe Paclitaxel, Dexamethasone Sodium Phosphate and Palonosetron.. You say that you would like reconsideration because this drug regimen is medically necessary.The Plan denied your request. The Plan says that these drugs are not being prescribed for a medically accepted indication.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Paclitaxel, Dexamethasone Sodium Phosphate and Palonosetron. Our reviewer says that the use of these drugs is supported by NCCN Guidelines. Our physician reviewer found the use of these drugs is not listed as not indicated, not supported or not recommended by any of the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the Paclitaxel, Dexamethasone Sodium Phosphate and Palonosetron. have been met.Therefore, we decided that the Plan has to pre-approvePaclitaxel, Dexamethasone Sodium Phosphate and Palonosetron.If the Plan does notagree 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to an outpatient rehabilitation program.You asked the Plan to pre-approvethe services. You say that the enrollee needs additional therapy.The Plan denied your request. The Plan says the services are not 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that an outpatient rehabilitation program at this provider is medically reasonable and necessary for the enrollee in this case. Outpatient rehabilitation orhome health rehabilitation would be potential reasonable options.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 serviceshave not been met.Therefore,we decided that the Plan does not have to pre-approveadmission to an outpatient rehabilitation program.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. Thereare no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2019 and November 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 8, 2019. The laboratory services on August 12, 2019 were provided before the end of that month.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for the services on November 5, 2019 was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing facility and should have been billed with POS code 32.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2019 and November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan (93880) provided on September 22, 2020.
You asked the Plan to pay for the duplex scan. You say that you would like reconsideration because this service is not specific to a place of service. The Plan denied your request. The Plan says the member was registered inpatient on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 93880 is not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service. It is not appropriate to bill an outpatient place of service code when the member is registered inpatient. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan (93880) provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from February 14, 2020, to February 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was stable for transfer.
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 the services. Our reviewer says that the inpatient services were not medically reasonable and necessary. Our physician reviewer found that by 2:24 p.m. on February 14, 2020, the enrollee was stable for ambulance transport with monitoring to a Plan facility because the enrollee's SOB and a-fib with RVR responded to treatment and she remained on RA with an SpO2 of 96%. She had no complaints of CP and remained hemodynamically stable and was deemed stable for repatriation to a Plan facility by the treating non-Plan ED. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from February 14, 2020, to February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires, per pair (A4557) provided September 14, 2020.You asked the Plan to pay forthe lead wires. You say that A4557 is not inclusive to A4595 and is separately reimbursable. Please reconsider the above referenced claim for payment or provide documentation supporting decision.The Plandenied your request. The Plan says a Tens unit was purchased in the previous 12 months. Records supporting medical necessity of the additional lead wires were not submitted. Therefore, service 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the leadwires have not been met.Therefore, we decided that the Plan does not have to pay forthe lead wires, per pair (A4557) provided September 14, 2020.
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 reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the members needs may be met at the current facility.
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 there are no services at the LTACH that the member requires that are not already available and covered at the current facility. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax, without contrast (71250).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says that this service is not medically necessary.
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 this service. Our reviewer says that this service is medically necessary. Our physician reviewer found that the enrollee has a significant smoking history (39 pack years, quit 2001) and a CT scan of the chest with several small pulmonary nodules. The scan from 2019 showed a change in one ground glass nodule of 9 mm to 4 mm solid. A follow-up computed tomographic angiography (CTA) is unable to visualize due to an acute infiltrate overlying the nodule. A request for a CT scan of the thorax was made. The enrollee is a high risk patient due to age and strong smoking history. The nodule changes in texture and size warrants a follow-up imaging at the twelve month interval. Therefore, this request for a CT scan of the thorax will be considered 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 this service have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax, without contrast (71250).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on July 1, 2020, to July 31, 2020.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were quoted that this would be $6 a month. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $496.00. The total amount you are being asked to pay is $99.20 ($496.00 x 20% = $99.20). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on July 1, 2020, to July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysa continued acute hospital stay can be offered until the enrollee can safely discharge to a lower level of care.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-approvethe LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan does not have to pay for emergency room services (99285 and 93005) provided to the enrollee on June 27, 2020.
You asked the Plan to pay for this service. You say that the Plan should pay for this service. The Plan denied your request. The Plan says the provider claim was submitted with errors that cannot be paid as billed. We overturned the Plans denial. The Plan requested a reopen and stated that the provider must submit a corrected claim with a modifier "25" before the claim can be paid. The Plan had original reported the claim was corrected however it was not resubmitted by the provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers. In this case, this claim cannot be paid due to the omission of the required modifier. Because this is a non-par or non-contract provider, the claim is reliant on the provider to submit the corrected claim before payment can be made. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285 and 93005) provided to the enrollee on June 27, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient services provided on January 28, 2020, through January 30, 2020.You asked the Plan to pay forthe inpatient services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the services are not supported by the record.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any explanation as to why these services are not supported. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay forinpatient services provided on January 28, 2020, through January 30, 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/orsend 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.