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

We decided that the Plan does not have to waive the copayment forinpatient hospital services provided June 26, 2020 to July 15, 2020.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that the copayment should be waived.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 $393 per day copayment for Inpatient Care. You have been asked to pay a $523.97 copayment for 2 days of inpatient hospital services. The inpatient hospital services fall within the Inpatient Care 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 forinpatient hospital services provided June 26, 2020 to July 15, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment (E0776, E0780, and E1399), the Part B drug (J3490), and the infection control supplies (S8301) provided on April 22, 2020.You asked the Plan to pay forCPT codes E0776, E0780, E1399, J3490, and S8301. 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. Therules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies (E0776, E0780, and E1399) provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.The rules also say that providers must report services correctly. Providers must report services withthe appropriate CPT code. In this, the CPT Code Manual definition of code J3490 is Unclassified drugs. We find that CPT code J3490 is not supported in the medical record. Specifically, the documentation did not support that Dantrium was administered on the billed date of service.The rulesalsosay under the Medicare Physician's Fee Schedule Database (MPFSDB) codes with a Status Code of "I" are "Not valid for Medicare purposes."We looked at the file and Medicare rules. In this case, CPT code S8301 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.Therefore, we decided that the Plan does not have to pay forthe durable medical equipment (E0776, E0780, and E1399), the Part B drug (J3490), and the infection control supplies (S8301) provided on April 22, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is not supported in the clinical literature.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS HF device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist visit provided on October 13, 2020.You asked the Plan to waive the copayment forthe specialist visit. 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 a specialist visit 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 $50 copayment for each specialist visit for Medicare-covered services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on October 13, 2020. You have been asked to pay a $50 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 forthe specialist visit provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dialysis services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe dialysis 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 neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the services you are requesting.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe dialysis services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia and respiratory failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTranscranial Magnetic Stimulation (TMS) treatments.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says you have not had an inadequate response to two or more medication classes.The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered under certain medical indications.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 requested services. Our physician reviewer found that the records donot show trials of 2 different agent classes in an inability to tolerate the medication. You havenot undergone a standard course of evidence-based psychotherapy,but haveshown a documentation of depression based on worsening of PHQ 9. It does not appear that the requested services areconsidered medically necessaryas you havenot met the criteria with adequate duration and dosage trial from 2 or more classes of medications as well as course of evidence-based psychotherapy.
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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approveTranscranial Magnetic Stimulation (TMS) treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlead wires (A4557) provided on September 4, 2020.You asked the Plan to pay forlead wires. You say that this is a payable code.The Plan denied your request. The Plan says this item should only be supplied once a year.The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary. We looked at the file and Medicare rules. The file shows that the enrollee was provided with a TENS machine less than 12 months prior to the lead wires being supplied. No medical records have been submitted to show that supplying lead wires more often than every 12 months is necessary in this case. Based on this information, we decided that Medicare rules for coverage of lead wires have not been met.Therefore, we decided that the Plan does not have to pay forlead wires (A4557) provided on September 4, 2020
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 28,
2021.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that that skilled therapy is not going to reverse your Parkinson's disease or
improve your cognitive function at this time.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before January 28, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pre-approve continued skilled nursing facility (SNF) services after January 28, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-rays provided on September 3, 2020 and October 9, 2020.You asked the Plan to waive the copayment forthe x-rays. 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 x-rays on the dates of service at issue in this appeal. The Plan says that the correct copayments have 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 $30 copayment for each basic imaging service (e.g., general x-rays or ultrasound). We looked at the file, the Plan's contract and Medicare rules. Medicare rules say that a global surgical package does not include diagnostic radiological services. The file shows that you received an x-ray on September 3, 2020 and October 9, 2020. You have been asked to pay a $30 copayment for each x-ray, totaling $60. The x-rays 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 forthe x-rays provided on September 3, 2020 and October 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for dental services (D6056, D0171, D9951, D9243, D7912, D6118, D1330, D0330) with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is outside of the plan's network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for dental services (D6056, D0171, D9951, D9243, D7912, D6118, D1330, D0330) with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dehumidifier (E1399).You asked the Plan to pre-approvethe dehumidifier. You say that you would like reconsideration because you live in a basement with no windows and have difficulty breathing.The Plan denied your request. The Plan says this is a non-covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvethe dehumidifier (E1399).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that the enrollee needs more therapy to return home.The Plan denied your request. The Plan says the enrollee is receiving adequate intensive rehab in the inpatient rehab facility.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 todetermine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the most recent documentation indicates that the enrolleerequires contact guard assistance with ambulation and she can ambulate with awalker up to 90 feet. She continues to require moderate assistance with transfers. Her speech issues have improved and she is tolerating an oral diet. Sheis medically stable and does not have any complex daily wound care, parental medications or requiredcare for a feeding tube. There has not been a significant decline in function due to the acute illness. Although the enrolleeis making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Therefore, an admission to a SNF for inpatient skilled rehab services is 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRamicirumab, Paclitaxel, Ondansetron IV, Dexamethasone, Xgeva for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe documentation does not support that the enrollee will be using these drugs as second-line therapy for the treatment of metastatic esophageal adenocarcinoma.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 the drug. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of paclitaxel and ramucirumab with dexamethasone and ondasetron with xgeva is not a standard 1st line treatment for metastatic esophageal cancer. The combination is not FDA approved, supported major drug compenida or supported by the medical literature. The service is 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 the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveRamicirumab, Paclitaxel, Ondansetron IV, Dexamethasone, Xgeva for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from January 17, 2019, through January 18, 2019 reported with principal diagnosis code N17.9.
You asked the Plan to pay for the inpatient hospital care. You say that this was billed correctly and should be paid at the reported DRG. The Plan denied your request. The Plan says the principal diagnosis code is not supported and, as such, the DRG billed is not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based in part on the reported diagnosis codes. In this case, you billed the inpatient services with the principal diagnosis code N17.9, which is defined as Acute kidney failure, unspecified. 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 inpatient hospital care. Our reviewer says that the reported principal diagnosis is not supported by the medical records provided. Our physician reviewer found in this case the member presented to the hospital with hyperkalemia and even though it was noted that the physician documented Acute Kidney Injury, this was as an impression (observation or suspicion). The medical records were consistent in documentation of the condition and clinical evidence supporting hyperkalemia. While the patient presentation warranted consideration of Acute Kidney Injury there was no initiation of renal replacement therapy or signs and symptoms of Acute Kidney Injury. The review has determined that the documentation provided did not support the reported principal diagnosis of N17.9 (acute kidney failure unspecified).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from January 17, 2019, through January 18, 2019 reported with principal diagnosis code N17.9.