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

We decided that the Plan does not have to pay forthe post-stabilization services provided from June 21, 2019 to June 23, 2019.You asked the Plan to pay for the post-stabilization services. You say that the managing physician(s) believe the services provided were medically appropriate and necessary at the level of care provided. You also say that any lesser level of care could have put the enrollee at an elevated risk for sudden clinical deterioration and adverse events.The Plan denied your request. The Plan says the hospital failed to seek pre-approval for admission from the Plan prior to providing the post-stabilization care services. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization services. Our reviewer says that the service was not medically necessary. Our physician reviewer found the review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services. Our reviewer found that there was no documentation provided necessitating post-stabilization care services from June 21, 2019 to June 23, 2019 at the non-Plan facility. Our physician reviewer also found that the post-stabilization care services were not medically necessary and reasonable.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the post-stabilization services have not been met.Therefore, we decided that the Plan does not have to pay forthe post-stabilization services provided from June 21, 2019 to June 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve bone marrow aspiration. The Plan denied your request. The Plan says there
is no evidence that the use of bone marrow aspirate increases fusion rates.
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 bone marrow aspiration. Our physician
reviewer found that bone marrow aspirate for the enrollee's procedure remains experimental. More research is
needed to show safety and efficacy. Therefore, the requested service is not medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspiration for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve Ondansetron. You say that the enrollee needs this to prevent nausea. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Ondansetron for the enrollee.
Benefits for Ondansetron 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for an echocardiography. You say that you were told that authorization was not required.The Plan denied your request. The Plan says no prior authorization was obtained.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 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 for an echocardiography provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocortisone valerate cream.You asked the Plan to pre-approvethe Hydrocortisone. You say that you would like reconsideration because the member has been stable on this medication since 2007.The Plan denied your request. The Plan says this medication falls under Part D coverage, not Part B.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-approveHydrocortisone valerate cream.Benefits for the Hydrocortisonemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 is clinically stable for transfer to an LTACH which can provide better pulmonary care since they specialize in vent weaning. The Plan denied your request. The Plan says the enrollee can receive clinically identical services by remaining in the current facility. The LTACH has no ability to provide better 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 the patient is currently undergoing treatment at an ACH for CoViD-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is tolerating tracheotomy collar weaning. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on September 6, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because the lumbar-sacral orthosis is medically necessary. The Plan denied your request. The Plan says the member has previously received the same item from a different provider within the last 5 years.
The Plan must follow Medicare rules. Medicare rules say that during the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Specifically, the record indicates that the member received the same item in May 2017. This is prior to the 5 years which Medicare determines is the reasonable useful lifetime for durable medical equipment. The record does not include any information supporting the replacement of this item was necessary due to loss or irreparable damage. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology services coded 81401 provided on September 19, 2019.You asked the Plan to pay for the molecular pathology services. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the services billed are not supported by the documentation.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 81401 is molecular pathology procedure level 2.Wefind that CPT code 81401 is not supported in the medical record. Specifically, this code represents molecular pathology procedure level 2. There is a more appropriate code for the ANKK1 test that was performed. Based on this information, we decided that Medicare rules for coverage of the molecular pathology services have not been met.Therefore, we decided that the Plan does not have to pay for the molecular pathology services coded 81401 provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Planhasto pre-approvediabetic shoes with foot insertsYou asked the Planto pre-approvethe shoes/inserts. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe documentation received shows diabetes, but no covered foot conditions.The Plan must follow Medicare rules. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 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 shoes/inserts. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found Medicare guidelines advise that in order for therapeutic and/or diabetic shoes and inserts to be covered, the beneficiary must be diagnosed with diabetes and one of the following conditions: previous amputation of other foot, or part of either foot, or history of previous foot ulceration of either foot, or history of pre-ulcerative callous of either foot, or peripheral neuropathy with evidence of callous formation of either foot, or foot deformity of either foot, or poor circulation in either foot. The medical documentation in this chart advises that the patient does have hallux valgus. This condition puts a significant amount of pressure both to the medial and medial plantar aspects of the first metatarsal head. This foot deformity can lead to painful callous formation and possibly ulceration. The medical documentation supports the need for therapeutic and/or diabetic shoes and inserts is this patient is a known diabetic with a foot deformity (hallux valgus) bilaterally.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 shoes/inserts have been met.Therefore, we decided that the Planhas to pre-approvediabetic shoes with foot inserts
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional dental crowns.
You asked the Plan to pre-approve 15 additional dental crowns. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you requested 1 extraction and 17 crowns. The Plan says that you are approved for 1 extraction and 2 crowns per the limitation of your supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental benefit clearly shows you are only allowed up to two dental crowns per calendar year. The plan approved the extraction and 2 dental crowns per the limitations of your supplemental dental benefit. Therefore, we decided that the Plan does not have to pre-approve 15 additional dental crowns.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a finger x-ray (73140) provided on November 26, 2019. You asked the Plan to pay for the finger x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 76140 was denied because it is a column II procedure to the column I procedure, 73130. 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 the finger x-ray has a bundled relationship with code 73130 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 finger x-ray (73140) provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ENTRESTO tablets.
You asked the Plan to pre-approve self-administered drugs. You say that this is a continuation of medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 ENTRESTO tablets.
Benefits for self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on October 23, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses LT, RT (L1833) and suspension sleeves LT, RT (L2397) purchased on October 30, 2019.
You asked the Plan to pay for the orthoses. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says the records provided do not support the service billed.
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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity.
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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses LT, RT (L1833) and suspension sleeves LT, RT (L2397) purchased on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on October 25, 2019.

You asked the Plan to waive the copayment for the biopsy. You say that there is only a $35 copayment when the service is done by the physician. You say that you were only expecting to pay the specialist copayment. 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 $375 copayment per visit for in-network, outpatient surgery.

You have been asked to pay a $375 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 biopsy provided on October 25, 2019.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 therequest to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found 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. The enrollee's medical status does not require intensive physician or nursing supervision only in an IRF. The enrollee is at a high functional level per therapy notes and does not require physical therapy and occupational therapy on an intensive level 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided to the enrollee from July 24, 2019 to July 25, 2019.
You asked the Plan to pay for the inpatient services. You say that the enrollee was admitted with the thought to be in limb threat. The Plan denied your request. The Plan says that the enrollee was admitted to the hospital without the required authorization.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient services. Our physician reviewer found that the enrollee with extensive peripheral vascular disease (PVD) presented with limb numbness. The enrollee has history of multiple stents. He was admitted with a plan for angiogram the following day. He was discharged when the CT angiogram showed stent to be colluded and bypass would be necessary. The admission was appropriate since limb loss was a possibility. Admission was appropriate as it was reasonable to assume that the enrollee would be in the hospital for 2 midnights. This situation was considered an emergency since limb loss due to PVD was a possibility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided to the enrollee from July 24, 2019 to July 25, 2019.
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.