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

e decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says IRF care is not medically necessary.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 the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.Youasked the Plan to pre-approvethe LTACH services. You say that this transfer is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that LTACHservices 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 thePlan 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 longterm 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-termacute 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 he is currently receiving care. Thedocumentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 80307 is drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service.

We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation submitted did not include a lab report or lab results for this testing. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown (D2750).

You asked the Plan to pre-approve a dental crown. You say that this service is medically necessary.The Plan denied your request. The Plan says the benefit limit has been exhausted for dental crowns.

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. The Plan covers a dental crown twice per calendar year. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a dental crown have not been met. Specifically, the record indicates the Plan has covered 2 crowns in 2020. This means that the benefit limit for dental crowns is exhausted for the 2020 calendar year. Therefore, we decided that the Plan does not have to pre-approve a dental crown (D2750).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the
requested CT scan. The Plan denied your request. The Plan says the documentation does not show the medical
necessity of the requested procedures. The Plan says that two other procedures are already scheduled.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the
requested CT scan is not medically necessary. Our physician reviewer found the enrollee reports abdominal
pain and nausea. The documentation notes a plan for a colonoscopy and endoscopy for evaluation of
symptoms with a differential diagnosis of acid reflux disease, peptic ulcer disease, and gastritis. The provider
did not discuss computed tomography imaging, a diagnostic concern requiring investigation by this study, or a
plan of care pending this study. Without the support of the documentation, medical necessity cannot be determined.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve computed tomography (CT) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received from June 3, 2020, to June 30, 2020.
You asked the Plan to waive the coinsurance for the dialysis services. You say that you were told that because you have stage 5 renal failure that this would be covered 100%. The Plan denied your request. The Plan says you were charged this coinsurance 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 dialysis services. You have been asked to pay 20% coinsurance for the dialysis services. The dialysis facility confirmed that you were advised of this cost sharing. 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 dialysis services you received from June 3, 2020, to June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulation (SCS) trial.
You asked the Plan to pre-approve the SCS trial. You say that you have tried other treatments and they have
not worked. You feel this is necessary. The Plan denied your request. The Plan says your condition does not
require this level of treatment.
The Plan follows Medicare rules. Medicare rules say that SCS trials may be covered for intractable low back
pain due to certain conditions as listed 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 the SCS trial. Our reviewer says that
the documentation does not support the requested SCS trial. Our physician reviewer found the enrollee is a
female with chronic low back pain, with morbid obesity and current smoking status. Her MRI shows multilevel
lumbar degenerative changes. She is taking Opiates, Gabapentin and an NSAID. She had an Epidural
steroid injection without lasting benefit. She had psychological screening for a SCS trial and was cleared.
There is no documentation of a surgical consultation, weight loss medications or procedures, attempts at
stopping smoking, or of an evidence-based indication for a SCS Trial.
There is no evidence-based indication for a SCS trial. She also has not had a multi-disciplinary approach to her
back pain or any attempts at mitigating her co-morbidities. The requested procedure is not medically
reasonable or 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 the SCS trial have not been met. Therefore, we decided that the Plan does not
have to pre-approve a spinal cord stimulation (SCS) trial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services should be covered because it was more convenient for the patient to use your facility.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found noexception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 26, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care you received from July 5, 2020, to July 9, 2020. You asked the Plan to waive the copayment for the inpatient hospital care. You say that you received poor care from the hospital so you shouldn't have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment per day for days 1-7 for inpatient hospital care. You have been asked to pay a $225 copayment per day for the inpatient hospital care. This copayment applies regardless of your satisfaction with the services received. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care you received from July 5, 2020, to July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion surgery to be performed by an out-of-network
provider.
You asked the Plan to pre-approve spine surgery. You say that Stealth and O-Arm technology will be used for
this surgery but are not available at other facilities, and you do not have privileges at other area hospitals. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this
provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.
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 spine surgery. Our reviewer says that
the enrollee does not meet the Medicare criteria for surgery with an out-of-network provider. Our physician
reviewer found the enrollee maybe treated safely by an in-network provider. The Stealth or O-Arm machine is
not needed to safely and effectively perform the spine fusion surgery. This is a common condition that does not
need out-of-network referral for surgery. Stealth and O-Arm are not the standard of care 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 spine surgery with an out-of-network provider have not been met. Therefore,
we decided that the Plan does not have to pre-approve lumbar fusion surgery to be performed by an out-ofnetwork
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing (G0481) provided on July 23, 2020.You asked the Plan to pay fordrug testing. You say that this was medically necessary.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that the patient's medical record must include an appropriate testing frequency based on the stage of screening, treatment, or recoveryandthe rationale for the drugs/drug classes ordered.We looked at the file and Medicare rules. The submitted medical records do not include a rationale for the drug testing ordered. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing (G0481) provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMems device for the enrollee.
You asked the Plan to pre-approve the CardioMems device. You say that this device is medically necessary.
The Plan denied your request. The Plan says that this device is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary. We asked our physician
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was
correct in denying the request to pre-approve the CardioMems device. Our reviewer says that the requested
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found
the records show the enrollee has Class III heart failure and is on multiple CHF medications with a prior
hospitalization for CHF in the past 1 year. Although she was initially stable and could be managed well with
clinical evaluations, recently she has developed increasing diuretic requirements, weight gain and edema that
has only partially responded to the clinical adjustment of medications and had over diuresis which resulted in
renal insufficiency as well. CardioMems device monitoring in this situation can provide additional heart filling
pressure data to better manage very complex diuretic and vasodilator regimens as occurs here. Data from the
Champions trial along with longer term follow-ups studies show a significant decrease in hospitalizations and
mortality with the use of this device. There is also published expert opinion in the cardiology literature as to its
appropriate use as well as reasonable patient selection criteria, all of which are met in this clinical instance.
Given the clinically significant symptoms of recurrent CHF, which appear very sensitive to volume loading
conditions, the complexity of the medical regimen and the prior hospitalization for CHF in the past year, use of
the CardioMems device is medically reasonable, meets CMS criteria for use, and has both clinical data and
expert opinion to support its use in this clinical situation. 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 CardioMems
device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMems device for the
enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on May 26, 2020.You asked the Plan to pay forthe services. The Plandenied 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 servicesat 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 forthe medical services provided to youby an out-of-network provider on May 26, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient therapy services provided on September 7, 2020 and September 8, 2020.You asked the Plan to pay forthe outpatient therapy services. You say that the therapy was medically necessary.The Plandenied your request. The Plan says the enrollee's plan year limit was met.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We looked at the file and Medicare rules. At the time of service the enrollee head met the calendar year limit for rehabilitation services.Therefore, we decided that the Plan does not have to pay foroutpatient therapy services provided on September 7, 2020 and September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services (99291) provided on July 8, 2020.You asked the Plan to pay forthe critical care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not support the service billed.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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the record. Specifically, the record does not include the amount of time rendering the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay forcritical care services (99291) provided on July 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the ambulance transport provided.

You asked the Plan to waive the co payment for the ambulance transport. You say that the ambulance bill was incurred during your hospital stay. You say that this should be covered under the hospital charge.The Plan denied your request. The Plan says the co payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 co payment for Medicare-covered ambulance benefits. This co payment applies to each one-way trip.

You have been asked to pay $212.02, which is less than the standard$290 co payment for the ambulance transport. The ambulance transport falls within the "Ambulance services"benefit category. The ambulance co payment applies to each one-way trip. 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 co payment for the ambulance transport provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 13, 2020.
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 code 27495 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 27495 is prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur. We find that CPT code 27495 is not supported in the medical record. Specifically, there is no documentation in the operative report of prophylactic treatment with our without methylmethacrylate. 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 January 13, 2020.