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

We decided that the Plan does not have to pre-approve Hyalgan injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says the requested visco supplement agent is subject to step therapy.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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the records do not indicate a trial and failure of the required drugs.  The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or likely have adverse effects 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Hyalgan injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xultophy (J3490).
You asked the Plan to pre-approve Xultophy. You say that this is necessary because the enrollee does not have an adverse reaction to this drug. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xultophy (J3490).
Benefits for Xultophy may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 15, 2019 to November 20, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct 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 $275 copayment per day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from November 15, 2019 to November 20, 2019. Therefore, you are responsible to pay a $275 copayment for days 1-5 (November 15, 2019 to November 19, 2019). $275 (copayment) x 5 (inpatient days) = $1,375.00.You have been asked to pay the total copayment amount of $1,375.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay provided from November 15, 2019 to November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc (J7324).
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of this service.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy such as Orthovisc is covered when the clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts.
We looked at the file and Medicare rules. The submitted medical records do not include radiologic evidence of osteoarthritis of the knee. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc (J7324).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug requires the following of medically accepted standards.
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 drug is not medically reasonable or necessary. Our physician reviewer found a review of the submitted documentation does not include current laboratory studies inclusive of hemoglobin, ferritin, and iron studies. Without the documentation, medical necessity cannot be determined. 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 Plan does not have to pre-approve Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on January 10, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says there was no delivery documentation proving that the enrollee received the orthosis.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on January 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on February 14, 2020.You asked the Plan to waive the copayment for a colonoscopy. You say that a tumor was found and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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 $350 copayment for surgery services provided in an ambulatory surgical center.The medical records show that the enrollee had a colonoscopy on February 14, 2020 and had polyps removed. Therefore, the colonoscopy is considered diagnostic, not preventative, and the enrollee is responsible to pay the $350 copayment. The enrollee has been asked to pay a $350 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora colonoscopy provided on February 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an incontinence garment and skin sealants, protectants, moisturizers, ointments provided on November 29, 2019.You asked the Plan to pay for the incontinence garment and skin sealants, protectants, moisturizers, ointments.The Plan denied your request. The Plan says 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 itemsat issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay for an incontinence garment and skin sealants, protectants, moisturizers, ointments provided on November 29, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain provided on October 2, 2019.
You asked the Plan to pay for the CT of the head or brain. You say that you would like the payment processed for this claim. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the head or brain provided on October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from November 28, 2019 to December 2, 2019.You asked the Plan to pay for the inpatient psychiatric hospital services. You say that the enrollee's treatment was medically necessary.The Plan denied your request. The Plan says that the enrollee could have had the care needed at an alternate level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric hospital services. Our reviewer says that the inpatient psychiatric hospital services were not medically reasonable and necessary for the enrollee in this case. An individualized treatment plan was not present in the provided medical records. The services were not reasonably expected to improve the patient's condition and were not provided for the purpose of diagnosis. The services were supervised and evaluated by a physician, but it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for these 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 inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from November 28, 2019 to December 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) provided on November 20, 2019.
You asked the Plan to pay for needle electromyography. You say that this was medically necessary. The Plan denied your request. The Plan says the records do not document that needle electrodes were used. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. 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 needle electromyography. Our reviewer says that this code is not supported in the records. Our physician reviewer found the submitted medical records do not document that needle electrodes were used, therefore, this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from November 4, 2019 to November 5, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says that at the time of admission there was not a reasonable expectation of a two midnight stay.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for inpatient hospital care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from November 4, 2019 to November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on November 14, 2019.You asked the Plan to waive the copayment for wound debridement. You say that every visit to this facility involved the exact same procedure. You say that you have never incurred an out-of-pocket cost before.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each covered surgery service in an outpatient hospital.You have been asked to pay a $100 copayment for the wound debridement. Wound debridement falls within the "Outpatient hospital services" benefit category. The wound debridement is considered a surgical service that was billed by the hospital. 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 wound debridement provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 19, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 19, 2020 to
February 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the rendering facility is also out-of-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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on February 19, 2020
to February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on December 13, 2019.You asked the Plan to pay for the anesthesia service. You say that you would like reconsideration because you believe these services should be covered.The Plan denied your request. The Plan says additional payment for extremes of age is no longer a covered benefit.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).We find that CPT code 99100 is not supported in the record. Specifically, per CMS the payment for CPT code 99100 is bundled into the payment for the primary procedure. Please note, the provider should not bill you for this service as payment for CPT code 01922 should be considered payment in full. Based on this information, we decided that Medicare rules for coverage of the anesthesia service have not been met.Therefore, we decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor supplies (CGM).
You asked the Plan to pre-approve CGM supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the enrollee has been using a BGM and performing testing four or more times a day. We looked at the file and Medicare rules. CGMs and CGM supplies are only covered when the enrollee performs testing four or more times a day and is insulin-treated. Review of the file only supports that the enrollee tests two times per day and does not inject insulin. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor supplies (CGM).
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found you were admitted to the hospital on May 27, 2020 with shortness of breath, weakness, and fatigue. You are currently undergoing treatment at an acute care hospital (ACH) for pneumonia. There is no evidence that you require services at the LTACH that are not available at the current setting. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day sensors.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day sensors.