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

We decided that the Plan does not have to pre-approve a Superion spacer.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain radiating into the right lower extremity with associated numbness and tingling. The requested Superion spacer is considered experimental/investigational for treatment of this enrollee's medical condition and is not 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion spacer.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical history of diabetes, chronic pressure ulcers, hypertension, chronic indwelling Foley catheter and advanced dementia who presented to the acute hospital on 07/22/2020 with a urinary tract infection. She was evaluated and treated in the hospital. She is weak and deconditioned and has been evaluated by physical and occupationaltherapy. She is not walking and she refuses to attempt to stand due to fear of falling. She declines transfers out of bed and she is maximum assist for activities of daily living. She is medically stable.Based on the medical records provided this enrollee does not require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records providedthis enrollee does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided daily skilled services are not required. Based on the medical records provided this enrollee does not require the services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room (ER) services rendered on January 5, 2020.You asked the Planto pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99285 is 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 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity.We find that CPT code 99285 is not supported in the medical record. Specifically, there is no documentation of any condition that requires high complexity of services. 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 forthe emergency room (ER) services rendered on January 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.You asked the Plan to pre-approve Keytruda. You say that the medication is 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 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that Keytruda is medically reasonable and necessary or safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from March 7, 2020 through March 8, 2020.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 pay for inpatient mental health care. Our physician reviewer found 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 beyond the dates in question as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. You did not require inpatient mental health treatment beyond the dates in question as noted above as you were not a danger to yourself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. You were treated under an individualized treatment plan found in the record. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of March 8, 2020 forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative
and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care from March 7, 2020 through March 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vision services and frames and lenses provided January 23, 2020 to January 25, 2020You asked the Plan to waive the coinsurance for the vision services. You say that the manager at the provider's office told you that they are only allowed to bill for a certain amount and nothing else. The providers office should have billed for all charges on your invoice.The Plan denied your request. The Plan says this claim was processed correctly per the plan benefits. For January 23, 2020 the claim was processed and paid with $0 for member responsibility. For January 25, 2020 the provider changed $439 for the frames and lenses. The plan paid $225 and there was a 20% discount from the provider leaving a balance of $51.20The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay any amount over the $375 eyewear benefit. for Vision care.You have been asked to pay $51.20 for the vision services. the vision services fall within the Vision care 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 coinsurance for the vision services and frames and lenses provided January 23, 2020 to January 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis Tab 5mg.You asked the Plan to pre-approveEliquis Tab 5mg. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveEliquis Tab 5mg.Benefits for Eliquis Tab 5mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past medical history of hypertension, aortic valve disease, left hip fracture and breast cancer who presented to the acute hospital on 07/20/2020 for revision of a left hip arthroplasty. She underwent surgical revision of the left hip arthroplasty and discharged to home on 07/25/2020. She was working with physical and occupational therapy in the hospital. She was walking (side steps) with minimum to moderate assistance and was minimum assist for transfers and minimum to maximum assist for activities of daily living. There is no report of an medically unstable conditions.Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveiron sucroseinjections (J1756).  You asked the Plan to pre-approveiron sucrose injections. You say that this is medically necessary for the enrollee's diagnosis.The Plan denied your request. The Plan says this is not covered for the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that Medicare covers iron sucrose injection as a first line treatment of iron deficiency anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplementalerythropoietin therapy.We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee is undergoing chronic hemodialysis andreceiving supplemental erythropoietin therapy.Based on this information, we decided thatMedicare rules for coverage of iron sucrose injections have not been met.Therefore, we decided that the Plan does not have to pre-approveiron sucrose injections (J1756).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 18, 2020 through February 19, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the documentation provided, the health plan's denial of continuing care should be overturned. The enrollee was admitted to the hospital with shortness of breath, altered mental status and weakness. The additional two days that the health plan is denying were not unreasonable given the enrollee's age, anorexia and general state of health. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 18, 2020 through February 19, 2020.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray provided on September 3, 2019.  You asked the Plan to pay forthe chest x-ray. You say that this claim should be paid by the Plan because hospice was revoked on September 2, 2019.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on September 2, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided on September 3, 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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no advantage in moving the member from the current acute care hospital to an LTACH.
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. 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 member 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 he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee requires rehab. The Plan denied your request. The Plan says that the enrollee's needs can be safely met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePercutaneous vertebral augmentation.You asked the Planto pre-approvePercutaneous vertebral augmentation. You say that the requested Percutaneous vertebral augmentation is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Percutaneousvertebral augmentation. 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 Percutaneous vertebral augmentation. Our reviewer says that the enrollee doesnot meet criteria for the requested Percutaneous vertebral augmentation. Our physician reviewer found the enrollee is with lumbar 2 fracture.  Criteria for kyphoplasty at L2 are not met. The CT scan shows that the fracture is chronic and mild. Kyphoplastyis not indicated for chronic fractures.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Percutaneous vertebral augmentation have not been met.Therefore, we decided that the Plan does not have to pre-approvePercutaneous vertebral augmentation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea neurostimulator foroveractive bladder.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the use of bladder wall stimulators is not considered reasonable and necessary.We looked at the file and Medicare rules. The service at issue is implantation of a bladder wall stimulator. This service is denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pre-approvea neurostimulator for overactive bladder
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic visit provided on March 24, 2020.
You asked the Plan to waive the copayment for the chiropractic visit. You say that the provider's office said you owe nothing for the service. 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 $20 copayment for Medicare-covered chiropractic services at an in-network or out-of-network specialist's office. You have been asked to pay a $20 copayment for the chiropractic visit. The chiropractic visit falls within the "Chiropractic 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 copayment for the chiropractic visit provided on March 24, 2020.