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

e decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. 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 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 reviewersays that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a 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 where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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-approveLTACH services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy (CPT code (s) 77525, 77522, 77523, and 77370), for the enrollee.You asked the Plan to pre-approvethe services. You say that it is medically necessary for the enrollee to receive proton beam radiation therapy.The Plan denied your request. The Plan says the records sent do not show that this request is 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 pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The Medicare have not been met.We looked at thisphysician'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 pre-approveproton beam radiation therapy (CPT code (s) 77525, 77522, 77523, and 77370), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to you by an out-of-network provider .You asked the Plan to pay forthe services. The Plan denied your request. The Plan says out-of-network services are not covered.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 had network providers available who could have provided 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 services provided to you by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe home ventilator breathing machine (E0466).You asked the Plan to pre-approvethe home ventilator breathing machine. You say that this service is medically necessary.The Plan denied your request. The Plan says the home ventilator breathing machine is not medically necessary.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator breathing machine. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic obstructive pulmonary disease, but there is no documentation of CO2 retention with an arterial blood gas while stable. In addition, you do not have neuromuscular disease or thoracic restrictive disease.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 home ventilator breathing machine have not been met.Therefore, we decided that thePlan does not have to pre-approvethe home ventilator breathing machine (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe chemotherapy infusion service (96413) and lab testing (80050, 83615) provided .You asked the Plan to waive the copayment forthe chemotherapy and lab testing. You say that you believe there was an error in processing this request.The Plan denied your request. The Plan says this provider was not in the Plan's network at the time of service. The claims processed 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 50% coinsurance for chemotherapy drugs provided out of network and a $65 copayment for lab services provided out of network.You were asked to pay $73.46 for the chemotherapy drugs, which were provided outside the Plan's network. The Plan's allowed amount for these drugs was $146.93 ($146.93 x 50% = $73.46). You were also asked to pay a total of $54.49 for two lab services. 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 chemotherapyinfusion service (96413) and lab testing (80050, 83615) provided .
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe CardioMEMS heart failure system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthe efficacy of this device is uncertain at this time according to leading authorities.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 pre-approve the system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS implantable pulmonary artery pressure monitoring device is medically reasonable and necessary for the enrollee 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 the system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe CardioMEMS heart failure system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary basedon 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 debility and weakness after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, andan intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePanniculectomy (CPT code 15830).You asked the Plan to pre-approvethe services. You say that there is a really bad rash underneath the skin. You state you cannot wait to have the surgery due to the amount of pain.The Plan denied your request. The Plan says you are not twenty-four (24) months or more out from the bariatric procedure, your weight loss has continued and has not stabilized. The Plan states you do not have documentationof active skin lesions.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 services. Our physician reviewer found although you have intertrigo, you are not twenty-four (24) months post-operative and have not achieved a stable weight. Therefore, you do not satisfy the LCD requirements and the requested service cannot be recommended.We looked at this physician's review, thefile, 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 pre-approvePanniculectomy (CPT code 15830).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. 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 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 reviewersays that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a 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 where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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-approveLTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.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 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 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 weakness and Non-ST-elevation myocardial infarction. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You donot require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.There is not a reasonable expectation that youwill 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formobile x-ray services (R0070) provided.You asked the Plan to pay forthe mobile x-ray services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was not filed with a valid place 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 R0070 is not supported in the medical record. Specifically, the claim was submitted with Place of Service 31. Place of Service 31 is limited to Part A covered inpatient stays. The record does not show the enrollee was an inpatient on an approved Part A stay at the time services were rendered. Based on this information, we decided that Medicare rules for coverage of the mobile x-ray services have not been met.Therefore, we decided that the Plan does not have to pay formobile x-ray services (R0070) provided
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe Medicare criteria for SNF care has 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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine eye refraction services (92015) provided .You asked the Plan to pay forthe routine eye refraction services. You say that you would like this claim reprocessed and approved for payment as specified by your contract.The Plan denied your request. The Plan says these services are not covered when obtained from a provider not contracted with the Plans vision vendor.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are obtained from a provider that is contracted with the Plan's vision vendor.We looked at the file and the Plan's rules. In this case, the provider who performed the eye refraction services is not contracted with the Plan's vision vendor. Based on this information, we decided that the Plan's rules for coverage of the routine eye refraction services have not been met.Therefore, we decided that the Plan does not have to pay forthe routine eye refraction services (92015) provided.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forCT of the head (70450) provided .You asked the Plan to pay forthe CT of the head. You say that you would like reconsideration because this service denied as a duplicate in error.ThePlan denied your request. The Plan says that CPT code 70450 is a column II code to column I code, 70470 which was billed on the same date of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We find that CPT code 70450 is supported in the record. Specifically, the record shows that the column I and column II codes were rendered by different providers. NCCI edits apply to line items billed with the same NPI. Based on this information, we decided that Medicare rules for coverage of the CT of the head have been met.Therefore, we decided that the Plan has to pay forCT of the head (70450) provided .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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe bench (CPT code E0245).You asked the Plan to pre-approvethe bench. You say that you need this transfer bench for the tub to prevent slips and falls.The Plan denied your request. The Plan says the bench is a comfort or convenience item; hygienic equipment; not primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because theyare not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvethe bench (CPT code E0245).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Covid-19 test provided .You asked the Plan to pay forthe Covid-19 test. You say that the service should be covered.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe Covid-19 test provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecial supplemental benefits for chronic patients.You asked the Plan to pre-approvethe supplemental benefits. The Plan denied your request. The Plan says you do not meet the coverage criteria.The Plan must follow Medicare rules.Medicare rules say that an MA plan offering special supplemental benefits for the chronically ill (SSBCI) must follow the above criteria. Your contract with the Plan clearly discloses the coverage criteria for supplemental benefits for chronically ill enrollees.We looked at the file and the Plan'srules.The submitted documentation does not show that you meet the Plan's coverage criteria for the requested supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvespecial supplemental benefits for chronic patients.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveToric intraocular lens to be inserted during your cataract surgery.You asked the Plan to pre-approvethe lens. You say that the service is medically necessary and just correcting the clouded lens will not by itself correct your vision.The Plan denied your request. The Plan says this lens is not covered by Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lens have not been met. Medicare does not cover special "Toric" intraocular lenses, if you choose to have these special lenses then you must pay the difference.
Therefore, we decided that the Plan does not have to pre-approveToric intraocular lens to be inserted during your cataract surgery.