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

We decided that the Plan does not have to waive the copayments for the photochemotherapy provided from June 2, 2020, to August 10, 2020.
You asked the Plan to waive the copayments for the photochemotherapy. You say that previous appeals have been overturned and you want these additional dates of service approved too. The Plan denied your request. The Plan says you have been asked to pay 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 $15 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $15 copayment for the photochemotherapy on each date of service. The photochemotherapy 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 copayments for the photochemotherapy provided from June 2, 2020, to August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional trips for routine transportation (A0120).
You asked the Plan to pre-approve the additional trips. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exhausted the allowable transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year. We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 60 additional trips for routine transportation (A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening analysis provided on September 8, 2020.
You asked the Plan to pay for the testing services. You say that the results allow physicians to make treatment decisions for the enrollee. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the screening analysis provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing visits provided to the enrollee from October 3, 2019 to January 8, 2020.
You asked the Plan to pay for the services. You say that the services should be paid for. The Plan denied your request. The Plan says this was routine and unauthorized care.
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 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 no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing visits provided to the enrollee from October 3, 2019 to January 8, 2020.
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 the enrollee needs trach/vent support. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute 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 physician reviewer found that the enrollee presented to the hospital with concerns of aspiration and respiratory failure requiring intubation. The enrollee remains nonresponsive on full vent support. There is no documentation of multiple unsuccessful weaning attempts. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an arthroplasty (23472-22) and tenodesis (23430-59) provided on September 17, 2020.
You asked the Plan to pay for an arthroplasty and tenodesis. You say that these procedures are documented. The Plan denied your request. The Plan says these codes and modifiers 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. 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 an arthroplasty and tenodesis. Our reviewer says that these codes are not supported. Our physician reviewer found the medical records provided do not include sufficient documentation describing the degree of added complexity and the substantial additional work performed on code 23472, meaning the use of modifier 22 for increased services is not supported. Code 23430 is bundled with primary procedure 23472 and is not separately reimbursed. Although modifier 59 was used to indicate this was a separate procedure, the medical records provided do not include sufficient documentation to validate that 23430 was a distinct separate procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an arthroplasty and tenodesis have not been met. Therefore, we decided that the Plan does not have to pay for an arthroplasty (23472-22) and tenodesis (23430-59) provided on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services, provided from July 17, 2020,
to July 22, 2020, at the DRG 682 rate.
You asked the Plan to pay for the inpatient hospital services at the DRG 682 rate. You say that the Plan should
pay the claim as DRG 682. The Plan denied your request. The Plan says based upon the Uniform Hospital
Discharge Data Set (UHDDS) rules, the corrected DRG 152 is more appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with N17.0, acute kidney failure with tubular necrosis.
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 inpatient hospital services at the DRG
682 rate. Our reviewer says that the review has determined that the claim was not submitted with the
appropriate DRG for this case. Our physician reviewer found in the documentation is a statement in the
discharge summary that the patient's reason for admission was dizziness related to chronic mastoiditis which is
DRG 152. The reviewed records do not validate N17.0, acute kidney failure with tubular necrosis as the
diagnosis for this admission.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services, provided from July 17, 2020, to July 22, 2020, at the DRG 682 rate.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental.
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 insertion of a CardioMEMS device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has complex cardiopulmonary disease and is on a complex medical and diuretic regimen that needs to be frequently titrated. Despite this, he has severe baseline symptoms and is seen frequently in the clinic for adjustment of his diuretics. He had a visit to the emergency department several months ago for decompensated congestive heart failure (CHF). Diuretic management, dosing, and frequency in the setting of severe CHF and renal insufficiency is very challenging and the CardioMEMS device has been shown in clinical trials to improve quality of life, heart failure symptoms and prevent recurrent hospitalization in patients like this with severe, complex and difficult to manage symptoms. 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 insertion of a CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
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: 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. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 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 physician reviewer found that the enrollee was admitted to the acute care hospital following a fall which resulted in rib and manubrium fractures and a tiny pneumomediastinum. LTACHs are certified as acute care hospitals, and in general, 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 he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccination provided out of network on September 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 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 a vaccination provided out of network on September 17, 2020.
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 a LTACH admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a LTACH admission.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that you appear to be improving and are more stable, requiring only short term additional acute care services that can be safely completed at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Additionally, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has been completed. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466). You say that the enrollee needs a home ventilator. The Plan denied your request. The Plan says no documentation of failure of maximal BiPap treatment requiring step up to the home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466). Our reviewer says that coverage criteria for a home ventilator are not met. Our physician reviewer found the patient improved on BiPAP in the hospital, although poor compliance limited efficacy. A home ventilator is not medically necessary because there has been no documented failure of BiPAP in the home setting when medically stable, and Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the intensive outpatient treatment program provided on January 27, 2020, to March 5, 2020 by an out of network provider.
You asked the Plan to pay for the intensive outpatient treatment program. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider is not Medicare certified for opioid use disorder treatment services, the code is not a payable code, and you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The provider in this case is not certified for payment of opioid use disorder services. The Plan did not pre-approve the services at issue. CPT H0015 is not a code payable by Medicare. 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 intensive outpatient treatment program provided on January 27, 2020, to March 5, 2020 by an out of network 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 these services are medically necessary. The Plan denied your request. The Plan says that you do not have a complex illness requiring more than 25 days of acute hospital care with daily doctor visits and specialized nursing.
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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your 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.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for services provided on June 16, 2020.
You asked the Plan to waive or reimburse these copayments. You say that your primary care physician refused to see you in person, and you do not have the means to participate in telehealth. You say that your physician could have seen you for no charge and you should not have had to see other providers. Therefore, you would like reimbursement for these copayments. The Plan denied your request. The Plan stated that these copayments were charged based on the services provided and the Plan contract agreement.
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 there is a cost share for urgent care, emergency room and specialist services. 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 $35 copayment charged for services provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and attachments.
You asked the Plan to pre-approve a power wheelchair and attachments. You say that these items are medically necessary. The Plan denied your request. The Plan says that the clinical notes do not indicate that you can use the requested group 3 power wheelchair safely and independently.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power wheelchair and attachments. Our reviewer says that a power wheelchair and attachments are not medically reasonable and necessary. There is evidence that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is evidence that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to weakness and instability. There is no evidence that you can safely operate a power mobility device. Our physician reviewer found that your condition does not meet Medicare criteria for a power wheelchair and attachments. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and attachments have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and attachments.