Persius/hicric huggingface dataset:
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 this is medically necessary.The Plan denied your request. The Plan says that the enrollee's needs can be met at a lower level of care.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 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-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled therapy is not medically necessary to restore or maintain function.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 77002 provided on August 27, 2019.You asked the Plan to pay forCPT code 77002. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that CPT Code 77002 is a Type 1 add-on code and must be reported with a proper Primary Code. In this case, CPT Code 77002 was billed without an appropriate primary code per Medicare guidelines.Therefore, we decided that the Plan does not have to pay forCPT code 77002 provided on August 27, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the oxygen concentrator provided on August 28,
2019.
You asked the Plan to pay for the oxygen concentrator (E1390). You say that the Plan should pay this claim.
The Plan denied your request. The Plan says that the Plan denied for PPG/Hospital Risk.
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. The Plan did not provide information to support their denial. Therefore, we
decided that the Plan has to pay for the oxygen concentrator provided on August 28, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approve MRI of the breast for the enrollee.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The PlansaysthatEntity the services were not considered medically necessary.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 in this case, the mastectomies and reconstructive surgery were done for cancer and not purely cosmesis. As there is a desire to evaluate for implant integrity as well as screening for underlying malignancy considering the history bilateral MRI is the best single test for such evaluations.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 Planhas to pre-approveMRI of the breast for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Chest (71250) provided onJuly 26, 2019.  You asked the Plan to pre-approve the CT scan. You say that the CT scan was medically necessary. The Plan denied your request. The Plan says a Chest X-ray is the standard of care.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the records do not provide specific clinical rationale for the requested Chest CT versus a Chest X-ray. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Chest (71250) provided on July 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided to the enrollee on July 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service) (CPT Code 99357) provided to the enrollee on September 18,2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported.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 CPT code 99357 is not supported in the medical record. Specifically, the documentation does not support for time limit of prolonged services of CPT Code 99357 also with CPT Code 99356. Based on this information, we decided that Medicare rules for coverage of the serviceshave not been met.Therefore, we decided that the Plan doesnot have to pay forprolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service) (CPT Code 99357) provided to the enrollee on September 18, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from June 15, 2019 at 1:43pm through June 16, 2019.You asked the Plan to pay forinpatient 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 review indicates that as of June 15, 2019 at 1:43pm the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care services. Post-stabilization care services June 15, 2019 at 1:43pm through June 16, 2019 at the non-participating facility were not medically necessary and reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient 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 inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from June 15, 2019 at 1:43pm through June 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from August 31, 2019 through September 2, 2019 by out-of-network providers.You asked the Plan to pay forthe medical services. You say that you were admitted to the provider as a crisis patient.The Plan denied your request. The Plan says you were voluntarily admitted to an out-of-network facility.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 forthe medical services provided from August 31, 2019 through September 2, 2019 by out-of-network providers
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) provided to the enrollee on August 30, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Documentation submitted did not include a valid order containing the ordering physician's NPI, Proof of Delivery or a Delivery Ticket. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) provided to the enrollee on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 13, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 did not pre-approve the service 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 laboratory services provided on August 13, 2019
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 this is medically necessary. The Plan denied your request. The Plan says the skilled nursing facility is no longer the appropriate level of care for this member.
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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's service provided on August 15, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 physician's service provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 7, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not contain documentation to support the coding criteria for the code billed on this date of service.
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 definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." 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 services at issue in this case were not coded correctly. Our physician reviewer found in the case of this enrollee, the records show that they are being prescribed gabapentin and Roxicodone. Definitive drug testing was performed on 6/7/2019 for multiple drug classes, including opioids, illicit drugs, sleep aids, stimulants, and benzodiazepines. It was stated in the provided records that the prior drug testing was from December, 2018 which was consistent and appropriate for the prescriptions at the time. No recent drug testing results showed inconsistencies and no information from the progress note from 6/7/2019 would suggest a second prescriber of opioids or that the patient might be using illicit drugs to help justify a broad definitive/confirmatory drug testing when simple point of care drug screening is more appropriate in this clinical setting. Therefore, the records do not support the coding of HCPCS G0482.
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 drug testing services provided to the enrollee on June 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCeftriaxone for the enrollee.You asked the Plan to pre-approveCeftriaxone. The Plan denied your request. The Plan says that drug coverage is limited to Part B drugs.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveCeftriaxone for the enrollee.Benefits for Ceftriaxonemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy visit provided from June 3, 2019 to July 25, 2019.You asked the Plan to waive the copayments forthe physical therapy visits. You say that you should not owe copayments for the physical therapy because you were inpatient. You say you paid out of pocket for June and July to stay at the facility and receive physical therapy. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for in-network Medicare-covered physical therapy and speech therapy services. You have been asked to pay a $25 copayment for each of the physical therapy visits. ($25 x 46 visits = $1,150). The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows the skilled nursing authorization ended on June 3, 2019.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 copayments forthe physical therapy visit provided from June 3, 2019 to July 25, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen (74170).You asked the Plan to pre-approvea CT of the abdomen. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee likely has polycystic ovary syndrome so a CT 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 wascorrect in denying the request to pre-approve a CT of the abdomen. Our reviewer says that a CT scan is not medically necessary at this time. Our physician reviewer found with normal Dehydroepiandrosterone levels, it is unlikely that the testosterone is being produced by an adrenal tumor. A more appropriate test would be a pelvic ultrasound.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT of the abdomen have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) of the abdomen (74170).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approveLTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says that based on the documentation provided, medical necessity has not been established.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. Medical records were not provided. Without this documentation, the Plan's denial is not substantiated.Therefore, we decided that the Plan has to pre-approvelong term acute care hospital (LTACH) services.