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

We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery sensor (CardioMEMS). You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due to his worsening heart failure.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in only 1 trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time, according to leading authorities, and is not recommended in current guidelines for the treatment of heart failure. This device should still be considered experimental/investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met.Therefore, we decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery sensor (CardioMEMS).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 9, 2019 to November 12, 2019.You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary.The Plan denied your request. The Plan says that the acute 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee with a newly diagnosed hepatocellular carcinoma was evaluated inthe Emergency Department on November 9, 2019. He was treated for abdominal pain, lower extremity swelling, hypokalemia and hyponatremia. The enrollee was given morphine for pain control, lovenox for deep vein thrombosis prophylactically and electrolyte replacement. His condition stabilized and improved, and he was discharged home on November 12, 2019 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission,the admitting physician reasonablyexpected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided November 9, 2019 to November 12, 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 foran office visit provided on August 29, 2019.You asked the Plan to waive the copayment foran office visit. You say that this was your annual wellness visit and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for primary care provider visits. The diagnostic codes submitted with the claim show that you received services beyond an annual wellness visit on August 29, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An 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 copayment foran office visit provided on August 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from October 2, 2019 to October 23, 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 the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were billed with the incorrect TOB code. 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 October 2, 2019 to October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy provided on October 24, 2019.
You asked the Plan to waive the copayment for the fine needle aspiration biopsy. You say that you were not informed the surgery was subject to a copayment. You say that you are questioning if the claim was billed correctly. 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 $250 copayment per visit for in-network, Medicare-covered surgical, IV therapy and blood transfusion services. You have been asked to pay a $250 copayment for the fine needle aspiration biopsy. The fine needle aspiration biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 fine needle aspiration biopsy provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided from June 28, 2019 to July31, 2019.You asked the Plan to waive the copayments for office visits. You say that you were told that you would not owe anything.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for primary care visits and a $35 copayment for specialist visits.You had primary care provider visits on June 28, 2019 and July 3, 2019. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $60.You had a specialist visit on July 31, 2019. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $95. You have been asked to pay the total amount of $95 for office visits. Office visits fall 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 copayments for office visits provided from June 28, 2019 to July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 4, 2019 by an out of network (OON) provider. You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and ordered by an in-network provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 medical services provided on December 4, 2019 by an out of network (OON) provider.
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 the enrollee's needs are being met in the current setting. The Plan says that LTACH will not provide additional services. The Plan says that the ongoing consultation services to ensure clinical stability are best handled in the current 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for CoVID-19. The enrollee required intubation/ventilation and subsequently received a tracheotomy. The enrollee's hospital course has been complicated by a pleural effusion, cholecystitis and renal failure, which appear to have limited ventilator weaning to this point. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2750 and D2950).
You asked the Plan to pre-approve the services. You say that you need your crown fixed, because you are not able to eat. The Plan denied your request. The Plan says procedures D2750 and D2950 are not listed/covered procedures and would not qualify as a plan benefit.
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 (D2750 and D2950) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D2750 and D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 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 procedure codes 35666, 35876, 35685, and 75710 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 35666 is bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery. Code 35876 is thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft. The definition of code 35685 is placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List separately in addition to code for primary procedure). The definition of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. We find that CPT codes 35666, 35876, 35685, and 75710 are not supported in the medical record. Specifically, the operative report does not include documentation that a bypass graft was performed to support code 35666. The operative report does not include documentation of a thrombectomy of arterial or venous graft to support code 35876. There is no documentation of an incision of skin overlying the arterial or venous graft to support code 35876. There is no documentation of a bypass graft patch to support code 35685. 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 surgical services rendered on October 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 14, 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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test 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 services rendered on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device and related accessories to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that utilization of this therapy will reduce the possibility of further complications or hospitalization. The Plan denied your request. The Plan says a participating provider can provide the requested 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and related accessories to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA) of the genicular nerves.
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is 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 the RFA. Our reviewer says that the requested RFA of the genicular nerves is considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an investigational/experimental procedure that is the subject of on-going clinical trials. The enrollee is not enrolled in a clinical trial. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePrednisone for the enrollee.You asked the Plan to pre-approvethis drug. The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvePrednisone for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667x2).
You asked the Plan to pre-approve a pneumatic compression device and segmental pneumatic appliance. You say that you respectfully disagree with the denial rational and ask for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG and coinsurance for injections provided by a participating provider on November 21, 2019.
You asked the Plan to waive the copayment for an ECG and coinsurance for injections. You say that these injections should have been included in the test. The Plan denied your request. The Plan says the correct coinsurance and copayment have been applied.
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 $75 copayment for outpatient diagnostic tests/radiological diagnostic service and a 20% coinsurance for outpatient diagnostic tests/radiological diagnostic service and Medicare Part B prescription drugs. You have been asked to pay a $75 copayment for an ECG and a 20% coinsurance of the allowed amount for injections. The total allowed amount is $465.78. The total coinsurance amount being charged is $93.16 ($465.78 x 20% = $93.16). The total amount you are being asked to pay is $168.16 ($75 + $93.16 = $168.16). An ECG falls within the outpatient diagnostic tests/radiological diagnostic service benefit category and injections falls within the Medicare Part B prescription drugs 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 and coinsurance for an ECG and injections provided by a participating provider on November 21, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on September 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 service 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 psychotherapy services (90834) provided on September 16, 2019 by an out of network (OON) provider.