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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more appropriate in this case. 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-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital services provided on November 12, 2019.You asked the Plan to pay forthe hospital services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says inpatient only HCPCS/CPT code, 56631 was billed having a status indicator C.The Plan must follow Medicare rules. Medicare rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Specifically, this claim was billed with CPT code 56631. CPT code 56631 is an inpatient only code and does not meet Medicare exception criteria for coverage under OPPS.Therefore, we decided that the Plan does not have to pay forthe hospital services provided on November 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment forthe duplex scan provided on June 11, 2020.You asked the Plan to adjust the copayment forthe duplex scan. You say that the  copayment should only be $25.The Plan denied your request. The Plan says you were charged this copayment 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 outpatient diagnostic tests. You have been asked to pay a $100 copayment for the duplex scan. The duplex scan falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to adjust the copayment forthe duplex scan provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, home with home health services, or home with outpatient therapy.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for thoracic spinal surgery to remove a mass compressing the epidural space. Medical problems
are stable. There are no identified problems that need inpatient medical management. There are no complex
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record
supports a need for physical and occupational therapy, but it does not support a need for an intensive
rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 15, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The cardiovascular risk assessment panel at issue in this appeal was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the cardiovascular risk assessment panel provided on April 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not have to waive the copayment formyocardial imaging, positron emission tomography (PET), perfusion study (78492) Rubidium rb-82, diagnostic, per study dose (A9555) Regadenoson injection (J2785) provided April 1, 2020.You asked the Plan to waive the copayment forthe diagnostic and injection services. You say that this was for a stress test pet scan which required an injection. The plan is treating this procedure as if it were two separate procedures and classified the injection as a drugThe Plan denied your request. The Plan says the claims were processed and the correct copayments were applied per the plan benefits.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 $150 copayment for each radiological diagnostic service, 20% coinsurance for each medical supply and 20% coinsurance for each covered Part B drug. for outpatient diagnostic tests and therapeutic services and supplies and Medicare Part B prescription drugs. You have been asked to pay $405.72 ($150.00 + $208.30 + $47.42) for the diagnostic and injection services. The diagnostic and injection services fall within the outpatient diagnostic tests and therapeutic services and supplies and Medicare Part B prescription drugs 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 formyocardial imaging, positron emission tomography (PET), perfusion study (78492) Rubidium rb-82, diagnostic, per study dose (A9555) Regadenoson injection (J2785) provided April 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from January 30, 2020, through May 12, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the Plan pays for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. We have also determined that these services are not urgent or emergent, nor were they approved in advance
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The provider at issue is a Licensed Professional Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from January 30, 2020, through May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on February 7, 2020, to June 7, 2020.You asked the Plan to waive the coinsurance for automatic external defibrillator. You say that you do not agree with this amount. The Plan denied your request. The Plan saysthe correct coinsurance has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay less than a 20% coinsurance of the allowed amount for automatic external defibrillator. The total allowed amount is $13,524.70. Your 20% coinsurance is $2,704.94 ($13,524.70 x 20% = $2,704.94). You are being asked to pay $2,333.14 which is less than your 20% coinsurance; therefore, the correct coinsurance has been applied. Automatic external defibrillator falls within the durable medical equipment (DME) and related supplies 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 thecoinsurance for durable medical equipment provided by a participating provider on February 7, 2020, to June 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on March 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services were not medically reasonable and necessary. Our physician reviewer found that the documentation does support that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation did support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Regarding hospital-to-hospital transfers, the documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for128 units of CPT 01214 provided on May 4, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the records do not support the number of units billed.The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.We asked our codingreviewer 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 128 units of CPT 01214 are not supported by the records provided. Our codingreviewer found that time units are computed by dividing the reported anesthesia time by 15 minutes. The documentation does not support 128 units billed.We looked at this coder'sreview, 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 for128 units of CPT 01214 provided on May 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mvasi, Ondansetron, Dexamethasone, Emend, Famotidine, Diphenhydramine for the enrollee.
You asked the Plan to pre-approve the drug regimen. You say that this is medically necessary. The Plan denied your request. The Plan says the approved sources don't support using this drug regimen to treat triple negative breast cancer.
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 regimen. Our reviewer says that the requested drug regimen is not medically reasonable or necessary. Our physician reviewer found the NCCN Guidelines Version 1..2020 Ovarian Cancer page MS-33 states that patients who relapse after less than 6 months after initial chemotherapy are considered to be platinum resistant. The enrollee has relapsed 3 months after completing Carboplatin/Taxol and beginning Avastin maintenance. Therefore she is considered to have platinum resistant ovarian cancer. Mvasi is not FDA approved for the requested use. The drug is not supported for the requested use in any of the CMS approved compendia. Although Mvasi is supported as an appropriate substitute for Avastin by the NCCN compendium, the compendium does not support the requested combination in this setting. The supporting drugs, Ondansetron, Dexamethasone, Emend Famotidine and Diphenhydramine are not indicated for use with Mvasi. They could be considered necessary and reasonable for use with Carboplatin and Taxol. 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 regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Mvasi, Ondansetron, Dexamethasone, Emend, Famotidine, Diphenhydramine for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's needs can be met safely 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 Medicarerules. 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: 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 can benefit from transfer to an LTACH for continuation of care of complex medical needs that require ongoing acute care. The Plan denied your request. The Plan says the enrollee is not appropriate for transfer to a LTACH at this time. Long-term acute care hospitals and acute care hospitals are licensed to provide the same level of care.
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 the enrollee has a history of hypertension, hyperlipidemia, tobacco dependence and alcohol dependence. The enrollee was admitted to the acute care hospital on October 24, 2020 with salicylate toxicity. The enrollee developed alcohol withdrawal and pneumonia, with respiratory failure requiring intubation. A tracheostomy and PEG tube have been placed. Attempts to wean the enrollee from the ventilator have been unsuccessful. The enrollee awakens to stimulation and makes eye contact. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services provided on July 16, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe psychotherapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules saythat 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 psychotherapy services provided on July 16, 2020, by an out-of-network (OON) provider.
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 you will heal sooner with these rehab services. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID 19 pneumonia. Your medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.