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

We decided that the Plan does not have to pre-approve additional inpatient psychiatric services June 19, 2020 and forward.
You asked the Plan to pre-approve additional inpatient psychiatric services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 additional inpatient psychiatric services. Our reviewer says that the documentation does not support that the requested additional inpatient psychiatric services are medically reasonable or necessary. Our physician reviewer found you were admitted to the acute inpatient psychiatric hospitalization on June 3, 2020 with Bipolar Disorder, Current Episode Manic Severe with Psychotic Features. You were compliant with treatment while not showing any acute threats to safety and were described as being pleasant and cooperative. The documentation does not support that you required additional inpatient psychiatric services as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety. 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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional inpatient psychiatric services June 19, 2020 and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for platelet rich plasma injections (0232T) provided on August
29, 2019.
You asked the Plan to pay for platelet rich plasma injections. You say that you were told this was the only
option besides surgery. The Plan denied your request. The Plan says this procedure is not covered under
Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that the services described by CPT code 0232T are
considered not proven effective or not medically reasonable and necessary and will be denied as such.
We looked at the file and Medicare rules. The service at issue has not been proven effective or medically
necessary. Based on this information, we decided that Medicare rules for coverage of platelet rich plasma
injections have not been met. Therefore, we decided that the Plan does not have to pay for platelet rich plasma
injections (0232T) provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for blood bank physician services (86077) provided on November 11, 2019.You asked the Plan to pay forthe blood bank physician services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this global service was previously allowed/paid on a previous claim.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file andMedicare rules. Based on this information, we decided that Medicare rules for coverage of code 86077 have been met. Specifically, code 86077 is a professional component only service. It does not require a 26 modifier when billing through the Physician FeeSchedule. The initial payment made by the Plan to the facility was for the technical component, as the facility did not provide a professional component. The code billed by the facility is considered the technical component. This would not be a duplicate payment.Therefore, we decided that the Plan has to pay forblood bank physician services (86077) provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Mighty Mack Rollator (E1399).
You asked the Plan to pre-approve the Mighty Mack Rollator. You say that you were given a walker that has a weight capacity of 400 lbs. You weight 415 and you want a Mighty Mack Rollator walker because and it will accommodate your weight. The Plan denied your request. The Plan says a brand name type of rollator is not medically necessary. The plan has approved a standard heavy duty rollator walker with seat that has a weight capacity of 500.
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 the Mighty Mack Rollator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Mighty Mack Rollator (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spravato.You asked the Plan to pre-approve Spravato. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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 Spravato.Benefits for Spravato 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3.You asked the Plan to pre-approveGelsyn-3. You say that the requested Gelsyn-3 is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Monovisc and Orthovisc first.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 Gelsyn-3. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with pain related to osteoarthritis of the left knee. He has failed conservative treatment and has had past Euflexxa injections. Gelsyn-3 injection is requested. The provided medical records do not indicate that the enrollee has tried and failed 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 Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approveGelsyn-3.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray of the Spine (72050) provided
February 6, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment for the X-ray should be
included in the copayment for the Computed Tomography (CT) scan done on the same date of service. The
Plan denied your request. The Plan says the correct cost-sharing was 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 $14
copayment for X-rays.
You have been asked to pay a $14 copayment for the x-ray. 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 X-ray of the Spine (72050) provided February 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee required supervision for bed rolling. The enrollee required maximum assistance to sit up, stand up, and transfers. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (72170) provided January 30, 2020.You asked the Plan to pay for the radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were billed as outpatient during a time when the enrollee was a hospital inpatient.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 72170 is not supported in the medical record. Specifically, the place of service on the claim indicates an outpatient service, however the enrollee was an inpatient at the time the services were provided. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met.Therefore, we decided that the Plan does not have to pay for radiology services (72170) provided January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for femoral fracture treatment (27245) provided on December 9,
2019.
You asked the Plan to pay for femoral fracture treatment. You say that this service was billed correctly. The
Plan denied your request. The Plan says the medical records do not specify a date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 27245 is not supported in the medical record. Specifically, the medical records do not
specify the date of service. This code cannot be verified for the billed date of service. Based on this
information, we decided that Medicare rules for coverage of femoral fracture treatment have not been met.
Therefore, we decided that the Plan does not have to pay for femoral fracture treatment (27245) provided on
December 9, 2019. provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 24, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810) and polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation (95811).
You asked the Plan to pre-approve polysomnography. You say that the requested services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for a diagnosis of OSA specific criteria must be met. 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 polysomnography. Our reviewer says that the services are not medically necessary. Our physician reviewer found it is stated that the enrollee seemed to be doing adequately at that time. There are no medical records submitted documenting symptoms/signs
suggestive of obstructive sleep apnea. In summary, the documentation provided does not support the medical necessity for the requested studies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810) and polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation (95811).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out of network (OON) provider.You asked the Plan to pre-approve radiation therapy to be provided by an OON provider. You say that you feel that you would get the best treatment from this provider.The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.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 radiation therapy to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D brush testing provided on January 15, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there are no medical records in the case file documenting that the requested testing was medically reasonable and necessary for the enrollee in this case. While it is speculated that WATS 3D biopsy testing can potentially improve the management of patients with Barrett's esophagus and esophageal dysplasia, and thereby, improve their outcomes, there are no convincing data in the medical literature demonstrating that such testing improves the management and outcomes of patients. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D brush testing provided on January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 3, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you had a repeat MRI to determine the cause of the pain. You say that you should not be responsible. 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 $270 copayment for advanced imaging services. You have been asked to pay a $270 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and 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 the copayment for the MRI provided on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approve exceptions to supplemental benefits. You say that your life could be in danger if you miss the appointment for cardiac catheterization.The Plan denied your request. The Plan says that additional mileage is not covered by your plan under any conditions.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the nail plate removal provided on February 4, 2020.
You asked the Plan to reduce the copayment for the nail plate removal. You say that you did not have surgery and should only be charged a $45 copayment for a specialist visit in the podiatry clinic. 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 $400 copayment for an outpatient hospital 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 $400 copayment for the nail plate removal.
You have been asked to pay a $201.88 copayment for the nail plate removal. The nail plate removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed separately by the outpatient hospital and the nail plate removal is considered 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 reduce the copayment for the nail plate removal provided on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. You asked the Plan to pre-approve the SNF services. You say that the enrollee needs rehab therapy in order to use her arm again. You say that it would be difficult for the enrollee to live at home while only being able to use one arm. The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care that must be provided in a SNF. The Plan says that the enrollee does not require daily skilled rehabilitation therapy. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs was alert with confusion, and was treated for pain with effect. The enrollee received physical therapy and occupational therapy in the acute hospital. the enrollee was at a minimal to moderate assist level with functional mobility, including gait up to a few steps with hand held assist. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, however they are not required on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhomemaker services (S5130) provided from July 19, 2019 to August 19, 2019.You asked the Plan to pay forhomemaker services. You say that you were told by the provider this would be covered.The Plan denied your request. The Plan says these services are not covered.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. The services at issue are custodial in nature. Based on this information, we decided that Medicare rules for coverage of homemaker services have not been met.Therefore, we decided that the Plan does not have to pay forhomemaker services (S5130) provided from July 19, 2019 to August 19, 2019.