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

We decided that the Plan does not have to pre-approve computed tomography of the heart (CT scan), without contrast material, with quantitative evaluation of coronary calcium (75521).You asked the Plan to pre-approve the CT scan of the heart. You say that the CT scan is medically necessary as this patient has had a previous elevated calcium score with cardiovascular risk being moderately high.The Plan denied your request. The Plan says the requested study is not covered by the health plan.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the CT scan. Our reviewer says that the enrollee does not meet criteria for coverage of a CT scan of the heart. Our physician reviewer found that based upon the records provided the enrollee has increased coronary risk including diabetes, hyperlipidemia and an elevated calcium score. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia establishedare periodically updated by expert committees and are endorsed by several national organizations.   These guidelines currently do not recommend routine performance of calcium scoring. Treatment change based on the results of routine calcium scoring has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Specifically, in this enrolleehigh intensity-statin medication is recommended regardless of the calcium score given her other significant risk factors.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography of the heart (CT scan), without contrast material, with quantitative evaluation of coronary calcium (75521).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on November 20, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you went to urgent care and were told to go to the hospital for a CT scan. You say you did not go to the emergency room and you should not pay the emergency room copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $110 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were seen in the emergency room.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 emergency room visit provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repeat lower back injections (64517, 64999 and 64450).You asked the Plan to pre-approve the injections. You say that the member has not had success with conservative treatment. The Plan denied your request. The Plan says that the member has experienced very limited short term relief to the initial injection and there is no evidence of physical therapy.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this is the standard approach to this syndrome.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 injections have been met. Therefore, we decided that the Plan has to pre-approve repeat lower back injections (64517, 64999 and 64450). 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe alcohol assessment rendered to you on September 24, 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 procedure code H0001 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The provider billed these services with procedure code H0001 (alcohol assessment). This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe alcohol assessment rendered to you on September 24, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on May 30, 2019.You asked the Plan to pay fordrug tests. You say that these services are covered by Medicare.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these tests were not medically necessary based onMedicare guidelines.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rulessay that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering provider is in-network or out-of-network with the Plan. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this claim. The Plan has denied payment for this claim because the enrollee's previous laboratory findings and risk assessment were not submitted to the Plan. However, as an independent reference laboratory you could not be reasonably expected to furnish these records directly to the Plan, and the Plan has not shown that they made any efforts to obtain these records. Therefore, the Plan has not shown that their decision to deny payment for these tests is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay fordrug testing provided on May 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 1, 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 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 that the Plan does not have to pay for the drug testing rendered on November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly meets Medicare criteria for coverage of LTACH services. The Plan denied your request. The Plan says the enrollee needs hospital care which an LTACH cannot do any better than the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH. Initially admitted with influenza, the enrollee subsequently suffered a perforated gastric ulcer. The enrollee was intubated/ventilated peri-operatively, but has since been extubated and is no longer on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided on September 18, 2019.You asked the Plan to pay for the outpatient clinic visit. You say that the claim has not been paid in full or under the terms of the contract.The Plan denied your request. The Plan says Original Medicare is responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided on September 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 4, 2019 to August 18, 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 the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that home health claims must be billed with the appropriate G and Q codes. We looked at the file and Medicare rules. The claims were not billed with the required G and Q codes. 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 home health services rendered from August 4, 2019 to August 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections (01992, 62323 and 77003).
You asked the Plan to pre-approve the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the prior injection provided one week of relief and no percentage was recorded.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prior steroid injection did not achieve a significant duration of pain relief. Additionally, there is no indication for monitored anesthesia 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections (01992, 62323 and 77003).
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 services are medically necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 they are 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 7, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (95811).
You asked the Plan to pre-approve the polysomnography. You say that your surgeon requires the sleep study prior to gastric sleeve surgery. The Plan denied your request. The Plan says there is no indication for a repeat sleep study prior to gastric sleeve surgery.
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 polysomnography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the most reasonable approach at this point would be to restart BiPAP therapy at the settings previously determined, and then to assess tolerance and effectiveness of this treatment after a month of use. A repeat PSG with PAP titration is not necessary to do this. 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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (95811).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve inpatient rehabilitation facility care. You say that an inpatient rehabilitation facility care admission is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility 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 inpatient rehabilitation facility care. Our reviewer says that the requested inpatient rehabilitation facility care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or in need of acute rehabilitation nursing care. While she may benefit from further physical and occupational therapy, she does not require an intensive rehabilitation therapy program. An inpatient rehabilitation facility admission is not medically necessary based her current functional status and medical stability. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for X-Ray examinations provided on November 14, 2018 and December 12, 2018. You asked the Plan to hold you harmless for X-Ray exams. You say that your treating physician ordered these tests, so you believe they should be covered. The Plan denied your request. The Plan says that the denial of payment for these services is correct. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that these tests would not be covered. Without this information, the Plan has not shown that their decision to deny payment for these services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to hold you harmless for X-Ray examinations provided on November 14, 2018 and December 12, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from the acute care. The Plan denied your request. The Plan says the enrollee does not require complex interdisciplinary therapy, or rehab supervision three times per week.
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 physician reviewer found that the enrollee is at moderate assist for bed mobility, contact guard assist for stairs, and maximum assist for lower body dressing. 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 her medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 14, 2019 through August 19, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 show that you received inpatient hospital care from August 14, 2019 through August 19, 2019. You are asked to pay a $150 copayment for the inpatient hospital care. 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 inpatient hospital care from August14, 2019 through August 19, 2019.