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 for the enrollee.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 this member does not have complex nursing, medical management, and rehabilitation needs that cannot be met at a less intensive level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 28, 2021, through January 29, 2021.You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the member was asymptomatic, no hemodynamic instability (hemoglobin stable after 1 unit of blood), no ongoing bleeding, no procedures/interventions required.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then 68-year-old female with a history of chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, anxiety and fibromyalgia who presented to the Emergency Department (ED) from home on January 28, 2021 with rectal bleeding.The review indicates that on initial presentation, the enrollee's hemoglobin was stable, and the enrollee was able to be discharged following a gastrointestinal consult and recommendations to be compliant with iron supplementation. The enrollee required no inpatient diagnostic studies or therapeutic interventions. There was no medical necessity for formal hospitalization. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 28, 2021, through January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0648) knee orthosis (L1833) and suspension sleeve (L2397) provided October 13, 2020.You asked the Plan to pay for the orthoses. You say that you received an EOB with a denial for misrepresented services. Attached please find, medical records, packing list, POD and WOL.The Plan denied your request. The Plan says the supplier is not enrolled/certified, evidence of misrepresented services and there is no claims history found with the ordering physician.The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0648) knee orthosis (L1833) and suspension sleeve (L2397) provided October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81401, 81403, 81404) provided on November 7, 2020.

You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81401, 81403, 81404) provided on November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of insulin injections at least three times per day.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria requires insulin use with adjustments in doses based on blood glucose levels. You are not taking fast-acting insulin, and are not adjusting your doses.

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 27, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications.

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36523 to substantiate our decision.

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 the laboratory services are not supported in the medical record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.
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 LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of 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 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.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan eye drops for the enrollee.You asked the Plan to pre-approve this drug. You say that this is medically necessary.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 Rocklatan eye drops for the enrollee.
Benefits for this drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Zilretta.You asked the Plan to pre-approve Zilretta. You say that this drug was approved before but is now being denied.The Plan denied your request. The Plan says the denial of authorization for Zilretta is correct, because the Plan requires a trial of dexamethasone or triamcinolone before it will approve Zilretta.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Zilretta. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Zilretta. Our physician reviewer found you have not tried and failed the Plan's preferred drugs of dexamethasone or triamcinolone. The documentation does not show that these drugs would likely be less effective and/or have adverse effects for you.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Zilretta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for outpatient rehabilitation services provided
from January 5, 2021, to January 28, 2021.

You asked the Plan to waive the co-payments for outpatient rehabilitation services. You say that you disagree
with the outpatient hospital charges and feel that you should only owe a $20 co-payment per each service. The
Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the
correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
co-payment for outpatient rehabilitation services provided at a specialist's office and a $40 co-payment for
outpatient rehabilitation services provided at an outpatient hospital facility.

The record shows that you received outpatient rehabilitation services from January 5, 2021, to January 28,
2021, for a total of 8 services, at an outpatient hospital facility. Therefore, you are responsible to pay a $40
co-payment per each visit. The total amount you owe is: $40 (co-payment) x 8 (outpatient rehabilitation services)
= $320.

You have been asked to pay the total co-payment amount of $320 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 co-payments for outpatient rehabilitation services provided from January 5, 2021, to
January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 14, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed on a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. 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 services provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on January 8, 2021.

You asked the Plan to pay for electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (93010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The records show this was a screening EKG with no history of previous cardiac or pulmonary disease. Based on this information, we decided that Medicare rules for coverage of electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (93010) have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on January 8, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve upper gastrointestinal endoscopy (43235).You asked the Plan to pre-approve upper gastrointestinal endoscopy (43235). You say that the requested upper gastrointestinal endoscopy (43235) is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested upper gastrointestinal endoscopy (43235).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 upper gastrointestinal endoscopy (43235). Our reviewer says that the enrollee meets criteria for the requested upper gastrointestinal endoscopy (43235). Our physician reviewer found the enrollee has significant upper abdominal pain radiating to the back as well as common bile duct dilation.  This symptom is specifically suggestive of serious organic disease.  No limitations in the local coverage determination apply for this indication.  The elements of the coverage rule are satisfied.  The requested service is recommended.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upper gastrointestinal endoscopy (43235) have been met.Therefore, we decided that the Plan has to pre-approve upper gastrointestinal endoscopy (43235).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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
February 21, 2020, through February 25, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the acute hospital stay was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 71 year old male who presented to the Emergency Department (ED) with seizure who was not compliant with Keppra prescription. The enrollee's blood pressure elevated in ED and he received hydralazine and Keppra in ED. On admission, vitals were stable, physical exam was unremarkable and asymptomatic except for baseline dementia. Based on the provided documentation, there was insufficient evidence to support the enrollee was to require hospital services that would likely cross two midnight.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 21, 2020, through February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.