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

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 1, 2019.
You asked the Plan to pay for the services. You say that you submitted complete documentation to support the services administered at the request of the referring physician. The Plan denied your request. The Plan says experimental procedures are not covered by the plan.
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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there is no evidence that the enrollee was had or was suspected of having a metabolic disorder affecting her medication metabolism. According to the documentation, the enrollee was actually responding well to her medications. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 Plan does not have to pay for lab services provided to the enrollee on August 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE).
You asked the Plan to pre-approve the TTE. You say that this is necessary. The Plan denied your request. The
Plan says the enrollee has no new signs or symptoms which would warrant this imaging.
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 TTE. Our reviewer says that the
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found
the patient is a 62-year old woman with a history of smoking, hyperlipidemia, Lyme disease, and neuropathy.
A nuclear stress test 03/21/2019 reported normal ventricular function and no ischemia. A clinic note dated
07/23/2020 documents no recurrent chest pain or dyspnea, a normal cardiovascular physical exam and a normal
electrocardiogram. A request was made for an echocardiogram.
Based on the records, the patient has no current cardiac symptoms, a recent normal stress test, a normal cardiac
exam and a normal electrocardiogram. In this circumstance, the documentation provided does not support the
medical necessity for an echocardiogram. Coverage criteria a not met since there are no documented covered
indications for the procedure and the test exceeds the patient's medical needs 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 TTE have not been met. Therefore, we decided that the Plan does not have
to pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from March 21, 2020 through March 23, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were not in the intensive care unit and that you were in a regular room and sent home the next day.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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). Review of the file shows that you were admitted on March 21, 2020 and discharged on March 23, 2020. You were asked to pay a $325 copayment per day from March 21, 2020 through March 22, 2020, days 1-2 of your inpatient hospital care. You were discharged on March 23, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-5. 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 forinpatient hospital care from March 21, 2020 through March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea duplex scan of lower extremity arteries (93925) and a duplex scan of extremity veins (93970).You asked the Plan to pre-approvea duplex scan of lower extremity arteries (93925) and a duplex scan of extremity veins (93970). You say that the requested duplex scan of lower extremity arteries (93925) and a duplex scan of extremity veins (93970) are medically necessary.The Plan denied your request. The Plan says the requested duplex scan of lower extremity arteries (93925) and a duplex scan of extremity veins (93970) are 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 applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a duplex scan of lower extremity arteries (93925) and a duplex scan of extremity veins (93970). Our reviewer says that the requested duplex scan of lower extremity arteries (93925) and a duplex scan of extremity veins (93970) are not medically necessary. Our physician reviewer found the enrollee is with a history of dyslipidemia, hypertension, obesity and coronary artery disease. A clinic note dated 07/23/2020 documents fatigue, leg cramps and back pain scheduled for injection. Physical exam documents normal lower extremities and no edema.Based on the records the enrollee has leg cramps that are not characterized, a normal lower extremity physical exam and no documented ankle: brachial index (ABI) or weak arterial pulses. In this circumstance the documentation does not support the medical necessity for either arterial or venous lower extremity Doppler exam. If concern for arterial insufficiency, then screening ABI recommended as a first step. Likewise, no documented edema on the most recent clinic note to support a suspicion of venous insufficiency. Coverage criteria are not met.
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 admitted to the hospital on July 15, 2020 with confusion, right sided weakness, and slurred speech. She was found to have an acute stroke. She is walking 10 feet with a rolling walker and moderate assistance. She needs minimum to moderate assistance with activities of daily living. The complexity of her medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy, but there is concern that she will not be able to fully participate in and benefit from an intensive therapy program 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 topre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided January 14, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was submitted incorrectly.
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 99239 is not supported in the medical record. Specifically, the record shows code 99239 was billed twice. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the extremity brace (L3908). You say that the physician ordered this durable medical equipment/Orthotic and it should be covered for the enrollee. The Plan denied your request. The Plan says prior authorization is required for a Non-Participating Provider.
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 medical services provided on January 2, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 95868 provided on December 17, 2019.You asked the Plan to pay forCPT code 95868. You say that the medical records support the billing of CPT code 95868.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 95868.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 95868 is Needle electromyography; cranial nerve supplied muscles, bilateral.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 CPT code 95868. Our reviewer says that the medical records do not support the billing of CPT code 95868. Our physician reviewer found based on the documentation provided, the enrollee received intraoperative neuromonitoring, inclusive of upper extremity EMG monitoring. There is no evidence that the enrollee received EMGs of muscles supplied by the cranial nerves. Therefore, the billing of CPT code 95868 is not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 95868 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 95868 provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 25, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.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 documentation of the ordering physician's intent that the tests 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 for the drug testing services provided on June 25, 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 these services are medically necessary. The Plan denied your request. The Plan says that you do not require three hours a day of therapy.
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. 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 pain medication and other medication management, skin care, and daily therapy can be provided at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 SNF care. Our reviewer says that the
services are necessary. Our physician reviewer found the enrollee does require skilled nursing or therapy
services on a daily basis. This enrollee does meet 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 SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 methylprednisolone acetate 40 mg injections (J1030)
provided on February 19, 2020 by the appealing provider.
You asked the Plan to pay for 2 methylprednisolone acetate 40 mg injections. You say that the services were
provided and payment should be rendered. The Plan denied your request. The Plan says based on the
documentation provided, Medicare billing criteria has not been 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.
In this case, the CPT Code Manual definition of code J1030 is a methylprednisolone acetate 40 mg injection.
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 2 methylprednisolone acetate 40 mg
injections. Our reviewer says that the documentation does not support the billed services. Our physician
reviewer found the medical records provided does not include documentation to corroborate that 2 units of
J1030 - Injection, methylprednisolone acetate, 40 mg was administered on February 19, 2020, therefore this
service cannot be verified.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 2 methylprednisolone acetate 40 mg injections have not been met. Therefore,
we decided that the Plan does not have to pay for 2 methylprednisolone acetate 40 mg injections (J1030)
provided on February 19, 2020 by the appealing provider.
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 admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past medical history of hypertension, hypothyroidism, arthritis, dementia and chronic obstructive pulmonary disease who presented to the acute hospital on 07/20/2020 with low back pain. He was evaluated in the hospital emergency department with physical examination, lab testing and imaging studies. He was found to have significant lumbar degenerative disease and spinal stenosis but no stroke or other acute issue. He was discharged to home with a Medrol Dosepak and a recommendation to get a follow-up with neurosurgery and a magnetic resonance scan as an outpatient. He is weak and unsteady; he has not had an evaluation with physical or occupational therapy. He is walking 5-10 feet with a rolling walker with maximum assistance and is minimum to moderate assist for transfers and activities of daily living. There is no report of any medically unstable issues otherwise.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. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says you have reached the 100-day benefit limit. Therefore, coverage criteria has not been
met.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from January 28, 2020 to May
21, 2020. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) care provided February 5 to February 13, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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 $178 per day copayment for days 21-29 for Skilled Nursing Facility services. You have been asked to pay a $178 per day copayment for days 21-29 for the SNF services, for a total of $1602. 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 Skilled Nursing Facility (SNF) care provided February 5 to February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.You asked the Plan to pre-approve Humira. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Humira is not covered under the enrollee's Medicare Part B benefit.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 Humira.Benefits for Humira may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.