Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on February 5, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says it is not appropriate to report unspecified, or left and
right diagnosis codes when a more specific (e.g. bilateral) code is available.
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 99212 is not supported in the record. Specifically, the claim includes two diagnosis
codes indicating laterality. There is a more specific, bilateral diagnosis code available. Based on this
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we
decided that the Plan does not have to pay for the office visit (99212) provided on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22867, 22868). You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has degenerative scoliosis which is an FDA contraindication for this procedure. Therefore, this request for insertion of lumbar interlaminar/interspinous process stabilization/distraction device (Coflex) would not be considered medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22867, 22868).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare criteria for transfer to an LTACH are not met.
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 she is currently receiving care. The documentation does not support that 25 or more days of additional acute hospitalization are reasonably expected. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve participation in a clinical trial for treatment with Keytruda for the enrollee.
You asked the Plan to pre-approve participation in a clinical trial and treatment with Keytruda. You say that the enrollee's participation in the clinical trial with Keytruda is medically necessary. The Plan denied your request. The Plan states the enrollee does not meet the criteria needed for Keytruda participation in the clinical trial is not able to be approved by the Plan. The Plan states the provider must contact Original Medicare and the facilitators of the clinical trial to determine if the enrollee can be registered. The Plan must follow Medicare rules. Medicare rules say that health Plans do not facility clinical trials. You are asking that the enrollee be approved to participate in a clinical trial for Keytruda. This request must be submitted to Original Medicare or the facilitators of the clinical trial. This is not an action that can be done for the enrollee by the Plan. Therefore, we decided that the Plan does not have to pre-approve participation in a clinical trial for treatment with Keytruda for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the right hand surgery provided on July 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for right hand surgery provided out of network. You say that the records provided support the service in dispute.The Plan denied your request. The Plan says there is not network deficiency for the services provided. The Plan says that there was no authorization on file for the out of network services.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 right hand surgery provided on July 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 10, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram for the enrollee.
You asked the Plan to pre-approve the echocardiogram. You say that this is medically necessary. The Plan denied your request. The Plan says doctor's notes are needed with more details about new or changing signs; or new exam findings to suggest heart valve or heart muscle problems.
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 echocardiogram. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has aortic valve replacement with a recent TEE about 7 months ago and a follow up cardiac MRI about 6 month ago confirming only mild aortic regurgitation and normal ventricular function in the setting of no chest pain or dyspnea. In this circumstance the records do not support significant clinical change to warrant a repeat echocardiogram less than 8 months from the prior exam. 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 echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vedolizumab.
You asked the Plan to pre-approve these services. 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unspecified ulcerative colitis without complications. Vedolizumab is specifically indicated for adults with moderately to severely active ulcerative colitis or Crohn's disease who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroid. The medical record in the case file documents that the enrollee is on Lialda. The documentation does not support that there has been inadequate response with, or intolerance of a tumor necrosis factor (TNF) blocker or immunomodulator; or an inadequate response with, intolerance to, or demonstrated dependence on a corticosteroid. The vedolizumab is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve vedolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup and interim partial denture for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare or the plan.
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 Plan does not have to pre-approve a core buildup and interim partial denture for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the testing provided on December 23, 2019.You asked the Plan to pay for the testing. You say that this testing is covered by Medicare and the testing was ordered to inform treatment decisions.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this testing was not medically necessary.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 follows these rules.The enrollee was referred for the testing by an in-network provider. The file does not show that the plan provided notice that the  testing would not be covered. Under Medicare rules, this means the testing is considered approved by the plan.Therefore, we decided that the Plan has to pay for the testing provided on December 23, 2019.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: Favorable

We decided that the Plan has to pay for the inpatient hospital care provided to the enrollee from November 15, 2019 to December 19, 2019.You asked the Plan to pay for these services. You say that these services were medically necessary.The Plan denied your request. The Plan says that that the enrollee has used up the Medicare hospital benefit.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.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 has not provided any type of documentation showing the enrollee has used up the Medicare benefit.Therefore, we decided that the Plan has to pay for the inpatient hospital care provided to the enrollee from November 15, 2019 to December 19, 2019.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 waive the copayment for the specialist services rendered on January
9, 2020.
You asked the Plan to waive the copayment for these services. You say that the provider said you wouldn't
have a copayment. The Plan denied your request. The Plan says the copayment was 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 $20
copayment per visit to a specialist.
Review of the file shows that you received an allergy shot during a specialist visit on January 9, 2020. Per your
contract with the Plan, there is a $20 copayment per visit to a specialist. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these
services was $10.36. Given that the allowed amount was less than the $20 copayment, you have been asked to
pay $10.36 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered
on January 9, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal/standby assist for functional transfers and basic activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-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 the requested
admission to an IRF.
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 the requested admission to an IRF. Our physician reviewer found the
enrollee has sepsis and end-organ damage, and dry left foot gangrene status post below knee amputation on
6/12/2020. The enrollee is now stable, and non-toxic. Medications appear to be providing appropriate
analgesia. The enrollee is mostly minimal/moderate assist for care including activities of daily living and is
afebrile.
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, wound care,
and daily therapy can be provided at a lower level of care. In this case, the member is mostly moderate/minimal
assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will
allow for measurable gains to be attained within a predicted period.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living. The Plan denied your request. The Plan says prosthetics are limited to basic equipment and custom or deluxe prosthetics and orthotics are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a powered upper extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on March 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. 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 the medical services provided to the enrollee by an out-of-network provider
on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.
You asked the Plan to pre-approve continued inpatient mental health care. You say that inpatient care is still medically necessary. The Plan denied your request. The Plan says the enrollee's condition has improved and she is no longer a threat to herself 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 continued inpatient mental health care. Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found based on the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the approved dates as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety or aggression. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower 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 continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care.