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

We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided August 26, 2019.You asked the Plan to pay for hospital discharge day management services. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.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 99239 is hospital discharge day management services of 31 minutes or more.We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted did not include a hospital discharge day management note with a documented duration time of 31 minutes or more. The submitted discharge summary is dated August 25, 2019 without any other documentation. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239) provided August 26, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProcrit.You asked the Plan to pre-approveProcrit. You say that the Procrit is medically necessary.The Plan denied your request. The Plan says a trial of the plan preferred drug Retacrit is required before alternatives can be considered.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 procrit. Our reviewer says that coverage criteria is not met. Our physician reviewer found there was no trial of the planned preferred drug and no reason why it would be contraindicated for this 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 procrit have not been met.Therefore, we decided that the Plan does not have to pre-approveProcrit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services beyond March6, 2020.You asked the Plan to pre-approveIRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 27, 2020 for weakness and was diagnosed with polymyositis. On March 4, 2020 she was noted to need minimal assist with standing and modified assist with walking 50 to 100 feet with a walker. The complexity of her nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy, but does not require an intensive therapy program in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services beyond March 6, 2020.
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 enrollee deserves the best outcome to return to his prior level of function. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care 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 physician reviewer found that in the case of this enrollee was admitted and treated at the current acute care facility with heart failure status post LVAD procedure for mechanical circulatory support. Mechanical ventilation was needed as well as antibiotics for pseudomonas pneumonia infection. A weaning attempt initially failed partially related to deconditioning. The infection had been improving significantly. A tracheostomy mask was sufficient for breathing support day and night, showing significant improvement to suggest less than 25 days of acute care should be needed. Although pulmonary care is still warranted at an acute care facility for the short term, long-term acute care is not likely to be needed and transfer to LTACH would not provide any needed treatments not already being provided and covered in the current setting. Therefore, based on the most recent records, this request for LTACH services will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 to an out-of-network urologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on October 23, 2019.You asked the Plan to waive the copayment forthe office visit. You say that this was a follow up visit to your surgery.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 $15 copayment for each in-network primary care doctor office visit for Medicare-covered services. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure. 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 office visit provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable gaseous oxygen system provided on November 1, 2019 by an out of network provider.You asked the Plan to pay forthe portable gaseous oxygen system. You say that the process to obtain the equipment was overwhelming and out of your control.The Plan denied your request. The Plan says prior approval was not requested.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 portable gaseous oxygen system provided on November 1, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable oxygen concentrator provided from August 15, 2019 to August 19, 2019.You asked the Plan to pay forthe portable oxygen concentrator. You say that you have heart problems and could not take your stationary concentrator while traveling.The Plan denied your request. The Plan says you did not have a physician written order for the portable oxygen concentrator.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  We looked at the file and Medicare rules. There is no physician order. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pay forthe portable oxygen concentrator provided from August 15, 2019 to August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 2, 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 claim was not billed correctly.
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 these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 2, 2019.
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 LTACH care is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 the patient is currently undergoing treatment at an acute care hospital (ACH) for meningitis following a recent craniotomy. The enrollee is noted to be close to her neurologic baseline. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 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 pay for a left ankle foot orthosis (L1971-LT) and a right ankle foot orthosis (L1971-RT) provided to the enrollee on May 22, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported in the medical records received.
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 orthoses. Our reviewer says that the documentation in the case file does not support that the requested bilateral ankle-foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD and the PIM. Our physician reviewer found the documentation includes several physician's progress notes. However, none of them address ankle pain. An appropriate physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. There are no medical records from the prescribing physician indicating the reason the bilateral ankle-foot orthoses were necessary. The documentation does not support that the bilateral ankle-foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the ankles and feet, and no evidence to support that the enrollee was evaluated or treated for a condition that supports the DME item(s) ordered. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for a left ankle foot orthosis (L1971-LT) and a right ankle foot orthosis (L1971-RT) provided to the enrollee on May 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care.You asked the Plan to pre-approvecontinued SNF care. You say that you need long-term care.The Plan denied your request. The Plan says you have reached the 100-day benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from October 2, 2019 to March 6, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in arow.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis.You asked the Plan to pre-approvea custom breast prosthesis (L8035). You say that the covered silicone breast prosthesis is heavy, hot, and looks like a blob. The Plan denied your request. The Plan says a custom breast prosthesis is not covered by Medicare or the Plan.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 a custom breast prosthesis (L8035) have not been met.Therefore, we decided that the Plan does not have to pre-approvea custom breast prosthesis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital after a fall with a pelvic fracture. You had stable vital signs and received dialysis three times per week. You received physical and occupational therapy in the hospital and need assistance with walking 25 feet with a rolling walker. You have no skilled nursing needs. You have skilled therapy needs but do not need skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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.You asked the Plan to pre-approve IRF care. You say that going to this facility will be more cost-effective than requiring transportation three times a week for treatment. You say that a different type of facility will not provide the care that you need.The Plan denied your request. The Plan says the information provided does not support that the enrollee requires intensive rehabilitation in an IRF on an inpatient basis.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. Our physician reviewer found the enrollee was medically stable with no evidence of a need for supervision by physical medicine and rehabilitation Physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program as he will not be able to tolerate the therapies. IRF admission is not medically necessary based on his current functional status and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the bladder irrigation procedure provided on November 6, 2019.You asked the Plan to reduce the copayment for the bladder irrigation procedure. You say that you went to the regular office to have the procedure done and believe the specialist's copayment should apply. You say the procedure is not a surgery. 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 $350 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center of hospital outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the bladder irrigation procedure.You have been asked to pay a $249.21 copayment for the bladderirrigation procedure. The bladder irrigation procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital. The record also shows that the bladder irrigation procedure is considered a surgical procedure on the bladder.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 reduce the copayment for the bladder irrigation procedure provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approve a specialist office visit. You say that your doctor was in-network 10 years ago. You say that you should not have to be forced to find a surgeon in-network.The Plan denied your request. The Plan says there are in-network providers available, provider and other provider, who can provide these services.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 specialist office visit to be provided by an out of network (OON) provider.