Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve functional endoscopic sinus surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that they do not see in medical information that the enrollee has not gotten better after one month of using nasal steroids and antibiotics.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The initial treatment of chromic sinusitis should include a course of one to three months inhaled steroids. The record does not indicate that the enrollee has failed steroids. The record does not indicate that the enrollee has a contraindication to inhaled steroids. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve functional endoscopic sinus surgery for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI scans of lumbar spine and cervical spine.

You asked the Plan to pre-approve MRI scans. 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. Medicare rules say that MRIs are covered only when they are medically 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 MRI scans. Our reviewer says that the documentation does not support that the requested MRI scans are medically reasonable or necessary. Our physician reviewer found you have lumbar disc disease with radiculopathy and Osteoarthritis. You are maintained on Ibuprofen and Gabapentin. You have tried and failed physical therapy in the past. The documentation does not support abnormal physical exam findings and no reported failure of conservative therapy. Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI scans have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI scans of lumbar spine and cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed until November 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 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.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospice enrollment.

You asked the Plan to pre-approve hospice enrollment. You say that you need hospice services to receive care for your condition. The Plan denied your request. The Plan says the record does not show that you have been diagnosed with an illness with a life expectancy of 6 months or less.

The Plan follows Medicare rules. Medicare rules say that for Medicare to approve Hospice, all of the above 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 hospice enrollment. Our reviewer says that the criteria for hospice enrollment have not been met. Our physician reviewer found there is no evidence in the submitted documentation that you currently require hospice services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hospice enrollment have not been met. Therefore, we decided that the Plan does not have to pre-approve hospice enrollment.
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 the enrollee needs LTACH care. The Plan denied your request. The Plan says based on Medicare guidelines, the Long-Term Acute Care Hospital (LTACH) services that you and/or your provider are requesting do not meet the requirements for approval.

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 health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for empyema and subsequent CoViD-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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 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 additional home health services.

You asked the Plan to pre-approve the additional home health services. You say that the additional skilled nurse visits and home aide services are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. Sufficient home health services were already approved.

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 additional home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation doesn't support that the enrollee requires skilled nursing services to provide treatment that is medically necessary. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The authorized weekly hours of home health aide services are sufficient to meet the member's needs for assistance with self-care tasks and mobility. 

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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180).

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that this service was necessary and should be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services (G0299).

You asked the Plan to pre-approve home health services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met.

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 home health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that the documentation does not support that the enrollee requires skilled nursing services or skilled rehabilitation services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits.

You asked the Plan to waive the copayments for specialist visits. You say that you did not go into the office and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $45 copayment for specialist visits.

The medical records show that you received specialist services. Therefore, you are responsible to pay the $45 copayment.

The medical records show that you received specialist services. Therefore, you are responsible to pay the $45 copayment.

The total amount you owe is: $90.

You have been asked to pay the total copayment amount of $90 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on March 10, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the submitted documentation did not contain sufficient detail to support the billed charges.

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 80307 and HCPCS G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on October 13, 2020.

You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this is not separately 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, we have confirmed that code 70450 has a Column One/Column Two relationship with code 70496, which was billed by the same provider on the same date of service, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections provided on July 8, 2020.

You asked the Plan to pay for the contrast media (A9505) and aminophylline (J0280). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include documentation of Thallium tl-201 thallous chloride, diagnostic, per millicurie or aminophyllin.

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 J0280 is Injection, aminophyllin, up to 250 mg, and the definition of A9505 is Thallium tl-201 thallous chloride, diagnostic, per millicurie. 

We find that CPT code A9505 J0280 is not supported in the medical record. Specifically, there is no documentation of aminophylline or 4 units of Thallium tl-201 thallous chloride being injected therefore the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the contrast media and aminophyllin have not been met. Therefore, we decided that the Plan does not have to pay for the injections provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for methylprednisolone acetate injections (J1040) provided on July 16, 2020.

You asked the Plan to pay for methylprednisolone acetate injections. You say that this is supported in the medical records. The Plan denied your request. The Plan says the records only support one unit of this code.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that 2 units of CPT code J1040 are not supported in the medical record. The medical record only supports 1 unit (80mg) of CPT code J1040. Based on this information, we decided that Medicare rules for coverage of methylprednisolone acetate injections have not been met. Therefore, we decided that the Plan does not have to pay for methylprednisolone acetate injections (J1040) provided on July 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services (90791) provided July 2, 2019.

You asked the Plan to pay for psychiatric services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for psychiatric services was not filed until September 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychiatric services (90791) provided July 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intradialytic parenteral nutrition (IDPN) services.

You asked the Plan to pre-approve IDPN services. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for IDPN services have not been met.

The Plan follows Medicare rules. Medicare rules say that parenteral nutrition is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition.

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 IDPN services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not meet the NCD criteria. The enrollee does not have severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN services have not been met. Therefore, we decided that the Plan does not have to pre-approve the intradialytic parenteral nutrition (IDPN) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code 63012.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records provided do not include documentation describing a Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) being performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code 63012.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.

You asked the Plan to pre-approve inpatient mental health treatment. You say that the 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 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 inpatient mental health treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 19, 2021 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and were not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to 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 inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.