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

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says there is no indication that the enrollee requires 24 hour medical monitoring, support or care to maintain his own safety or the safety or others.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee was not shown to be a danger to himself or others. The enrollee was without agitation or aggression, without perceptual disturbance, including auditory or visual hallucinations. The enrollee does not meet the criteria for this request.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promartx injections for the enrollee.
You asked the Plan to pre-approve Promartx. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is considered investigational.
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 Promartx. Our reviewer says that the Promartx is not considered medically reasonable and necessary in this case. Human amniotic membrane/amniotic fluid (stem cell transplantation) for treatment of osteoarthritis is considered investigational and not accepted as standard therapy in the general medical community. Our physician reviewer found that the enrollee's condition does not meet criteria for Promartx. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Promartx have not been met. Therefore, we decided that the Plan does not have to pre-approve Promartx injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemodenervation services rendered on November 13, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes J0585 and 64615 are not supported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 64615 is chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (e.g., for chronic migraine). The definition of code J0585 is injection, onabotulinumtoxinA, 1 unit. We find that CPT codes 64615 and J0585 are not supported in the medical record. Specifically, there is no documentation does not support that an injection of onabotulinumtoxinA, 200 unit, was administered to support code J0585 or that chemodenervation of muscles was performed to support code 64615. 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 chemodenervation services rendered on November 13, 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 LTACH care is medically necessary. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee's ongoing care needs include respiratory support with oxygen supplementation, oral steroid taper, surveillance laboratory studies, tight blood glucose management, pressure wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea dental implant.You asked the Planto pre-approvethe services. You say that you would like a dental implant so you will be able to eat.The Plandenied your request. The Plansaysthis serviceis not covered under your benefit package.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 coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvea dental implant
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 00914 provided on January 8, 2020. You asked the Plan to pay for CPT code 00914. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. CPT code 00914-QZ is not supported. The medical records provided include documentation that indicates the anesthesia service 00914 was performed with medical direction/medical supervision, therefore, the use of a QZ modifier indicating services delivered without medical direction by a physician is inappropriate. The modifier choices that are appropriate when there is medical direction/medical supervision are QY, QX, and AD. Based on this information, we decided that Medicare rules for coverage of CPT code 00914 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 00914 provided on January 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says that the use of Reblozyl is not FDA approved in a patient with transfusion dependent low risk myelodysplastic syndrome with isolated del(5q) chromosomal abnormality, and without ring sideroblasts.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Reblozyl. Our reviewer says that Reblozyl is not medically reasonable and necessary for the enrollee in this case. Reblozyl is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Reblozyl. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain indications. 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 radiofrequency ablation. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has trialed physical therapy. The enrollee had one set of diagnostic medial branch blocks with excellent relief. The LCD criteria requires dual diagnostic blocks with greater than 80% with each. Here, there was no second block performed. Therefore, the request is not medically reasonable or necessary at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 11, 2019 to August 13, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment as the inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital admission 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 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 the 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 evaluated in the emergency department for a urinary tract infection that had progressed. He was noted to have mild tachycardia and hypotension. The enrollee was given intravenous fluids and antibiotics with improvement. Ongoing hospital care was recommended. The medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. The admission notes state that the enrollee was symptom free. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. He had stable vital signs and no complaints at the time of admission. Orders included serial laboratory studies, intravenous fluids, antibiotics, and telemetry. Inpatient services were not supported by the documentation.
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 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 August 11, 2019 to August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have a very serious foot condition that causes your foot to be deformed. You say that the requested orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on December 18, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that you did not have any medical problem or diagnosis of a medical problem. You say that routine vision care has a $0 copayment. 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 visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk. You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that the medical eye exam was related to cataracts and hypermetropia. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam provided on December 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered from September 5, 2019 to September 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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that a mental health counselor is not eligible to participate in Medicare. We looked at the file and Medicare rules. The file shows that the provider is licensed as a mental health counselor. 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 outpatient mental health services rendered from September 5, 2019 to September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cardiovascular procedures and office visit provided on October 16, 2019 and October 17, 2019. You asked the Plan to waive the cost share for the cardiovascular procedures and office visit. You say that you had no idea you would be paying this much for the operation. You say that you cannot pay these bills. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for in-network, Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $50 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in an in-network specialist's office. The cardiovascular procedures fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The office visit falls within the "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 cost share for the cardiovascular procedures and office visit provided on October 16, 2019 and October 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from September 5, 2019 to September 19, 2019.You asked the Plan to pay forhome health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, these services were billed with an incorrect type of bill code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from September 5, 2019 to September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toilet safety rail.
You asked the Plan to pre-approve the rail. You say that this is required to provide assistance to readily arise from the toilet seat in the bathroom. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a toilet safety rail.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy and voice analysis provided on November 12, 2019.You asked the Plan to waive the copayment for the laryngoscopy and voice analysis. You say that you didn't have anything resembling surgery. You say that you expected a $40 specialist copayment.The Plan denied your request. The Plan says the copayments 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 $125 for each in-network, Medicare-covered outpatient hospital facility visit and $35 per day, per in-network provider, for diagnostic procedures and tests. You have been asked to pay a $125 copayment for the laryngoscopy and a $35 copayment for the voice analysis. The laryngoscopy falls within the "Outpatient hospital services" benefit category. The voice analysis falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The laryngoscopy is considered a surgical procedure that was provided by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the laryngoscopy and voice analysis provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to get prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 skilled nursing services provided on November 7, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on November 20, 2019.
You asked the Plan to pay for the laboratory testing. 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 a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the file shows that medical records from the enrollee's psychiatrist office were not provided to support that the enrollee had a diagnosis that would make these laboratory tests provided diagnostic and not provided for screening purposes. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on November 20, 2019.