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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says there is no medically necessary skilled care needed to warrant the requested level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications and insulin. The enrollee had stable vital signs and was treated for pneumonia. The enrollee received physical therapy in the acute hospital. The enrollee was independent with bed mobility and transfers. The enrollee required supervision for gait to short distances with a rolling walker. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 19, 2019 to November 7, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.ThePlan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items atissue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by "the provider" from August 19, 2019 to November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). You asked the Plan to pre-approve Prolia. You say that this is medically necessary.The Plandenied your request. The Plan says the enrollee does not have osteoporosis.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. The rules also say that for Prolia to be considered medically necessary, all of the above listed information must be present.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 Prolia. Our reviewer says that the documentation does not show that Prolia is medically necessary at this time. Our physician reviewer found the documentation does not include the information required by the Local Coverage Article. Medical necessity cannot be determined.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be received in another setting.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee'smedical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe seat lift mechanism of a seat lift chair.You asked the Plan to pre-approvethe seat lift mechanism of a seat lift chair. You say that you have knee and back painand would feel more comfortable sitting and resting in a seat lift chair. The Plan denied your request. The Plan says the physical therapy notes show you are able to independently transfer from sitting to standing.The Plan must follow Medicare rules. The rules say that a seatlift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift recliner have not been met.Therefore, we decided that the Plan does not have to pre-approvethe seat lift mechanism of a seat lift chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT colonographyscreening (74263) provided on July 16, 2019.You asked the Plan to pay for the CT colonography. You say that this service was medically necessary. The Plan denied your request. The Plan says Medicare guidance says CT colonography screening, including image postprocessing is never covered.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 74263 is not supported in the record. Specifically, per Medicare guidance, code 74263 for screening computed tomographic colonography is nationally non-covered. Based on this information, we decided that Medicare rules for coverage of the CT colonography have not been met. Therefore,we decided that the Plan does not have to pay for CT colonography screening (74263) provided on July 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99283) provided on July 10, 2019.You asked the Plan to waive the copayment foran ER visit. You say that that on July 8, 2019 you were taken to the ERfor a nosebleedthat did not stop. The ERdoctor put a rhino rocket into your nose and told you it could come out in two days by her doctor. You tried to see your doctor but could not and was referred to the physician's assistant. You were then referred to an ear, nose and throat doctor but the doctor would not take you in case there was active bleeding. You were advised to go back to the ERto have the rhino rocket taken out. You don't feel this is fair when neither your doctor, nor the ear, nose and throat doctor would do the job.The Plan denied your request. The Plan says emergency services have a $90 copayment per visit.Therules 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 $90 copayment for emergency careper visit. You have been asked to pay a $90 copayment for an ER visit. This servicefalls within the emergency care 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 foran emergency room (ER) visit (99283) provided on July 10, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study described by CPT code 95810.You asked the Plan to pre-approvea sleep study (95810). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says a sleep study described by CPT code 95811 was already approved and CPT code 95810 is a duplicative procedure.The Plan must follow Medicare rules. The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used.The services at issue are described by CPT code 95810. The Plan has approved a sleep study described by CPT code 95811. CPT code 95810 is a column II code with a modifier indicator of 0 when billed with code 95811; therefore, code 95810 cannot be approved in conjunction with the approved 95811.Therefore, we decided that the Plan does not have to pre-approvea sleep study described by CPT code 95810.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on July 11, 2019.You asked the Plan to pay forlab tests. You say that you are appealing with supporting documentation.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted did not include a signed physician order or laboratory requisition for the tests billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee by "the provider" on August 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided thatthe Plan does not have to pay forthe drug testing rendered to the enrollee by "the provider" on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on July 2, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says thedocumentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 forthe drug testing services provided on July 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Citalopram Hbr for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrolleeneeds this for dementia.The Plan denied your request. The Plan says that drug coverage is limited to Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveCitalopram Hbr for the enrollee.Benefits for this drugmay be available underMedicare Part D.Contactthe 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 waive the copayment forthe office visit provided on October 30, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the card did not have an effective date of November 1. You say that the additional $30 should be waived.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 $40 copayment per specialist visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls withinthe "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 copayment forthe office visit provided on October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe immediate maxillary denture (D5130), and the immediate mandibular denture (D5140).You asked the Plan to pre-approvethe immediate maxillary denture, and the immediate mandibular denture. You say that  The Plan denied your request. The Plan says the request for immediate dentures exceeds the benefit allowance. The Plan also says that immediate dentures were previously approved on December 6, 2019.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 coverageand immediate dentures are a covered service, thebenefit allowance has been reached.The Plan says they previously approved immediate dentures on December 6, 2019.Therefore, we decided that the Plan does not have to pre-approvethe immediate maxillary denture (D5130), and the immediate mandibular denture (D5140).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvetherapeutic apheresis.You asked the Planto pre-approvethe services. You say that the enrollee is at highrisk of extreme decline in quality of life without this approved.The Plandenied your request. The Plansaysthis is not covered for this diagnosis.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found in the case of this enrollee, the provided records did not show evidence of any of the covered indications listed in the coverage rules.
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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetherapeutic apheresis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Gastrectomy (43632) provided on November 6, 2018.You asked the Plan to pay for the Gastrectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for a Gastrectomy (43632) provided on November 6, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low doseCT Scan (G0297).You asked the Plan to pre-approvethe CT Scan. You say that based on the member's last PET/CT Scan, it was recommended that she receive one every 6 months to evaluate if hercancer returned.The Plan denied your request. The Plan says your records show that you only have a 10-year pack history.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan have not been met. Specifically, the record indicates the member has a 10 pack-year history. This does not meet Medicare coverage criteria.Therefore, we decided that the Plan does not have to pre-approvea low doseCT Scan (G0297)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay for drug testing services provided on May 13, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysHealthcare Common Procedure Coding System (HCPCS) G0483 remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided on May 13, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you are not ready to go home.The Plan denied your request. The Plan says that physical therapy indicated that your prognosis was excellent for maintaining your current level of function at a long term custodial care setting.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 todetermine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skillednursing facility (SNF) 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-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 the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the medical records note this enrollee was admitted recently with hematemesis and diplopia. MRI confirmed an acute stroke. Previous to this stroke, the enrollee was modified independent and accessing the community. Co-morbid conditions include cervical radiculopathy and hypertension. Now, the enrollee is hemodynamically sable and minimal assist for transfers and basic mobility per recent therapy notes. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing medication management, skin care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains 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-approveacute inpatient rehabilitation facility (IRF) admission and services.