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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Ongoing medication management, skin care, and therapy can be provided at a skilled nursing facility. A less intensive, longer duration of therapy would allow for measurable gains to be attained within a predicted period. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on March 29, 2019.
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 procedure code J3490 is not supported.
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 J3490 is unclassified drugs.
We find that CPT code J3490 is not supported in the medical record. Specifically, there is no documentation to
support the billing of 20 units of this code. Only one unit is appropriate for this code. 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 pay for the services rendered on March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the efficacy of the device is uncertain at this time.
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 requested services. Our physician reviewer found that the enrollee has a history of hypertension, obesity, coronary artery disease, chronic kidney disease, stroke, bipolar disorder, mitral regurgitation, deep venous thrombosis and congestive failure with preserved ejection fraction requiring hospitalization. In this circumstance, therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device is still considered experimental or investigational. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
You asked the Plan to pre-approve the out-of-network services. You say that you would like reconsideration as this procedure will save you from being in the hospital, losing too much blood and not having to be under anesthesia. The Plan denied your request. The Plan says the care you are requesting is available in-network.
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 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. 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 the medical services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64490, 64491, and 64492
provided on August 8, 2019.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The 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 64490 is Injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or
CT), cervical or thoracic; single level.
The CPT Code Manual definition of code 64491 is Injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical
or thoracic; second level (List separately in addition to code for primary procedure).
The CPT Code Manual definition of code 64492 is Injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical
or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure).
We find that CPT codes 64490, 64491, and 64492 are not supported in the medical record. Specifically, the
medical records did not include documentation of a diagnostic or therapeutic agent Injection(s) of the cervical
or thoracic paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT); for a single level; therefore, code 64490 cannot be verified. The medical records did not
include documentation of a diagnostic or therapeutic agent injection(s) of the cervical or thoracic paravertebral
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT); for the
second level (Listed separately in addition to code for primary procedure); therefore, code 64491 cannot be
verified. The medical records did not include documentation of diagnostic or therapeutic agent injection(s) of
the cervical or thoracic paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), of the third and any additional level(s) (Listed separately in addition to code for
primary procedure); therefore, code 64492 cannot be verified. Based on this information, we decided that
Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan
does not have to pay for the injection services coded 64490, 64491, and 64492 provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator (E0748).
You asked the Plan to pre-approve the osteogenesis stimulator. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this service is considered 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 pre-approve the osteogenesis stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of a bone stimulator for C2 dens fractures remains experimental. More research is needed to show efficacy and 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 the osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve osteogenesis stimulator (E0748).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the routine EKG services and to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine provided on August 14, 2019.
You asked the Plan to waive the copayment for the routine EKG services and to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine. You say that you disagree with the amounts owed. The Plan denied your request. The Plan says the claims were processed correctly per your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 copayment for outpatient diagnostic tests.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus, diphtheria toxoids and acellular pertussis vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to tetanus, diphtheria toxoids and acellular pertussis vaccine.
Your copayment requirement for the EKG services is $55. However, the allowed amount for this service is $20.48. Since this is less than your copayment requirement, you were charged the lesser amount.
You have been asked to pay a $20.48 copayment for the routine EKG services. You have also been asked to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine. The routine EKG services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the routine EKG services and to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 23, 2019 by out of network provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 the drug testing provided on July 23, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transplant related lodging, meals and transportation S9975 from August 25, 2019 to August 26, 2019.
You asked the Plan to pay for the travel and lodging. You say that these services were related to transplant preparation and therefore should be covered. The Plan denied your request. The Plan says the travel and lodging was for an esophagogastroduodenoscopy, which was determined to not be transplant related.
The Plan must follow Medicare rules. Medicare rules say that the travel and lodging are not covered because they are not primarily medical in nature. While travel and lodging may be appropriate in this case, neither the plan nor Medicare offers coverage of these items. Based on this information, we decided that Medicare rules for coverage of the travel and lodging have not been met. Therefore, we decided that the Plan does not have to pay for transplant related lodging, meals and transportation S9975 from August 25, 2019 to August 26, 2019.
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 requested facility is closer to your family. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF with close physician and nursing supervision. While you may benefit from and participate in additional therapies of physical therapy and occupational therapy, you do not require this or appear to be able to tolerate this therapy on an intensive rehabilitation therapy program 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAlrex ophthalmic solution for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveAlrex ophthalmic solution for the enrollee.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc knee injections.
You asked the Plan to pre-approve the injections. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says authorization for Synvisc has been denied because the enrollee has not had ample trial of other treatments (conservative therapy) to meet Medicare criteria.
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 Synvisc injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient had recent knee surgery for a meniscal tear. At least 3 months of healing is needed postoperative. Therefore, Synvisc injections are not medically needed at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Synvisc injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc knee injections.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says the LTACH care is not considered medically reasonable and 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 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 the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was readmitted to the hospital on January 15, 2020 for MRSA bacteremia. He needs minimal assist with dressing and transfers from shower seat and grab bars. He is independent with grooming and bed mobility. The documentation does not reveal that his medical status is ready to transfer to a rehabilitation facility. There is concern noted on January 30, 2020 that the physician would like to wait to ensure the enrollee does not need a wash out. Additionally, his right foot is noted to be more swollen on the January 30, 2020 progress note and the etiology is unclear. His functional status also does not require the intensityof therapy at 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transport on August 9, 2019.You asked the Plan to pay fora second transport.You say that there were two transports on the same day.The Plan denied your request. The Plan says you did not provide requested documentation of a second transport.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. There are no records of a second transport in the case file. Based on this information, we decided that Medicare rules for coverage of asecond transporthave not been met.Therefore, we decided that the Plan does not have to pay fora secondambulance transport provided on August 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond
January 30, 2020.
You asked the Plan to pre-approve these services. You say that you are being discharged too soon. The Plan
denied your request. The Plan says the continued services are 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted
to the SNF on January 10, 2020 and received oral and inhaled medications. You had stable vital signs. You
received physical and occupational therapy and need moderate assistance with bed mobility and maximal
assistance with transfers. You need varied levels of assistance with activities of daily living. You have no
skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis.
As a practical matter, you do not require the necessary services on an inpatient basis at the 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services beyond January 30, 2020.