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

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve the inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this 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 pre-approve the inpatient psychiatric services. Our reviewer says that the criteria for coverage of inpatient psychiatric care have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on June 9, 2021, with Schizoaffective Disorder Bipolar Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. She was found to be disorganized and paranoid. The patient was compliant with treatment while not showing any acute threats to safety. 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 beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
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 this enrollee meets the criteria for long term acute care and is stable and suitable for a transfer. The Plan denied your request. The Plan says the enrollee is not medically stable to transfer at this time and does not meet the criteria for an LTACH.
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 that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN (G0299) and direct skilled nursing services of an LPN (G0300).
You asked the Plan to pre-approve the direct skilled nursing services of a RN and direct skilled nursing services of an LPN. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 direct skilled nursing services of a RN and direct skilled nursing services of a LPN. Our reviewer says that these services are not shown to be medically necessary or reasonable. Our physician reviewer found you do not have documented skilled nursing needs. 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 direct skilled nursing services of a RN and direct skilled nursing services of a LPN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a RN (G0299) and direct skilled nursing services of an LPN (G0300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane (J9264).

You asked the Plan to pre-approve Abraxane. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Abraxane. Our reviewer says that the requested use of Abraxane is not supported. Our physician reviewer found Abraxane is not FDA-approved for the enrollee's diagnosis. This use is also not supported by the major drug compendia or by clinical research that appears in a CMS approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane (J9264).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99213 provided on October 19, 2020.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are
spent face-to-face with the patient and/or family. 

We find that CPT code 99213 is not supported in the medical record. Specifically, this service was billed with modifier 25 in conjunction with an annual wellness visit. The plan already approved payment for the wellness exam, blood draw, wheezing evaluation, and stool check. No acute problems were addressed or needed attention on this date of service. This means that the office visit is not supported by the documentation in conjunction with the annual wellness visit. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the walker, the radiology services, and the office visit provided from January 11, 2021 to February 15, 2021.

You asked the Plan to waive the cost share for these services. 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 walker, radiology services, and an office visit on the dates of service at issue in this appeal. The Plan says that the correct cost share 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 20% coinsurance for Durable medical equipment, a $35 copayment for x-ray services, and a $45 copayment for specialist visits. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a walker on January 11, 2021. You have been asked to pay a 20% coinsurance for these services, totaling $12.39. These services fall within the Durable medical equipment benefit category. 

The file shows that you received x-ray services on February 5, 2021 and February 12, 2021. You have been asked to pay a $21.32 copayment for the x-ray provided on February 5, 2021, which is less than the contracted $35 copayment amount. You have been asked to pay a $35 copayment for the x-ray services provided on February 12, 2021. The x-ray services fall within the Outpatient diagnostic tests benefit category. 

The file shows that you received an office visit provided by a specialist on February 15, 2021. You have been asked to pay a $45 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 amounts 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 cost share for the walker, the radiology services, and the office visit provided from January 11, 2021 to February 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a SNF admission.You asked the Plan to pay for the SNF admission. You say that it is not safe for you to go home without more treatments to physically help you.The Plan denied your request. The Plan says criteria for admission to a SNF have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pay for a SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and power seat elevation (E2300).

You asked the Plan to pre-approve an expandable controller and power seat elevation. You say that these items are necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan follows Medicare rules. Medicare rules say that these items are subject to the criteria listed in the Medicare rules section. 

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 an expandable controller and power seat elevation. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the expandable controller is medically necessary. Records indicate the enrollee is independent with eating and upper extremity strength indicating she has the strength and function to control the power options with their own switches. In addition, the power seat elevation feature is not covered because it is primarily not medical in nature. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and power seat elevation have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and power seat elevation (E2300).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-emergency transportation; taxi (A0100) exceeding 60 miles.

You asked the Plan to pre-approve routine transportation exceeding 60 miles. You say that you would like the ride approved to see an OON provider. The Plan denied your request. The Plan says this trip is more than 60-miles and therefore is not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation to plan-approved locations not exceeding 60 miles per one-way trip, every year. We looked at your request, the records in the case file, and the rules. In this case the trip being requested is over 60 miles. The Plan has providers within the maximum trip distance that could provide the services. 

We find no exception that would require the Plan to cover the requested trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-emergency transportation; taxi (A0100) exceeding 60 miles.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy. You say that you are making progress, but still need assistance. The Plan denied your request. The Plan says that you do not need the ongoing skills of a physical therapist.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional physical therapy. Our physician reviewer found that there is documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. You still demonstrate deficits in transfers and records indicate difficulties with staff transfers; a recent incident of sliding out of your wheelchair was documented. Further physical therapy treatment to focus on safe transfers appears medically reasonable and necessary. The specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy have been met. Therefore, we decided that the Plan has to pre-approve 10 additional physical therapy visits.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection (J0897) and a prophylactic injection (96372) provided on June 11, 2020.

You asked the Plan to waive the coinsurance for a denosumab injection and a prophylactic injection. You say that these injections have been covered in the past. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay 20% coinsurance for a denosumab injection and a prophylactic injection. The allowed amount of the claim is $1,173.42, resulting in a coinsurance obligation of $234.69. The EOC confirms that 20% is the required coinsurance for this service. A denosumab injection and a prophylactic injection fall within the Medicare Part B prescription drug benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a denosumab injection (J0897) and a prophylactic injection (96372) provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for prophylactic injections (96374, 96375) and outpatient hospital services (86923) provided on January 21, 2021, to February 11, 2021.You asked the Plan to waive the cost-share for injections and outpatient hospital services. You say that you are being charged a copayment versus a coinsurance, resulting in a higher amount billed.The Plan denied your request. The Plan says the copayment you are being charged is correct.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$250 copayment for outpatient hospital service. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each additional service, of an outpatient hospital visit.
You have been asked to pay a $250 copayment and a 20% coinsurance for injections and outpatient hospital services. The EOC confirms that $250 is the required copayment for outpatient hospital services including surgery services rendered in an in-network outpatient hospital. The EOC also confirms that 20% is the required coinsurance for additional services for each visit in an in-network outpatient hospital. On your date of service for January 21, 2021, you have been asked to pay a $250copayment. On this date of service, you are also asked to pay a 20% coinsurance for an additional injection. The allowed amount of that service is $38.22, resulting in a coinsurance obligation of $7.64($250 + $7.64 = $257.64 total cost-share).On your date of service for February 1, 2021, you have been asked to pay a $250 copayment.On your date of service for February 11, 2021, you have been asked to pay a $142.51 copayment. The records show the Medicare Allowed Amount is $142.51, which is lower than your copayment of $250 per the EOC.Your total cost-share amount is $650.15 (257.64 + $250 + $142.51 = $650.15). 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 cost-share for prophylactic injections (96374, 96375) and outpatient hospital services (86923) provided on January 21, 2021, to February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the stem cell therapy provided from November 18, 2020, to December 8, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that stem cell therapy is covered for the indications established in the applicable LCD.

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 requested stem cell therapy is not medically reasonable and necessary. Our physician reviewer found that the enrollee is an 80-year-old female with chronic joint pain. Flower AmnioPatch(TM) and injection were provided for treatment of her condition. Based on Medicare guidelines, the Flower AmnioPatch(TM) (Q4177- dehydrated amniotic membrane allograft that is used as a wound covering for postsurgical wound care) and trigger point and joint injection do not meet the requirements for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the stem cell therapy provided from November 18, 2020, to December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of radiographic images (D0210), and the topical application of fluoride varnish (D1206) received February 4, 2021.You asked the Plan to pay for the dental services (D0210, D1206). You say that the requested services should be covered by the Plan.The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The requested services are not covered regardless of whether they were provided by an in-network or out-of-network dental provider. Therefore, we decided that the Plan does not have to pay for the complete series of radiographic images (D0210), and the topical application of fluoride varnish (D1206) received February 4, 2021.