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

We decided that the Plan does not have to pay for the laboratory services, noninvasive ear or pulse oximetry for oxygen saturation, and outpatient hospital clinic visit provided on October 31, 2019.You asked the Plan to pay for the laboratory services, noninvasive ear or pulse oximetry, outpatient hospital clinic visit. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee.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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the laboratory services, noninvasive ear or pulse oximetry for oxygen saturation, and outpatient hospital clinic visit provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 25, 2019.You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file shows that the documentation does not indicate that the provider discussed the need for the billed supply code. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency services provided to the enrollee on September 30, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the interpretation and report are not authenticated by the rendering physician.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 93010 is "Electrocardiogram, routine ECG with at least 12 leads."We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly, or supported by the medical records. Our coding reviewer found the medical records provided does not include an interpretation and report , therefore, this service is not eligible for reimbursement.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay foremergency services provided to the enrollee on September 30, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Cologuard test provided to the enrollee on April 29, 2019.
You asked the Plan to pay for the test. You say that you are the only provider of Cologuard in the area. The Plan denied your request. The Plan says that the plan did not provide an answer within the timeframe.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not provide any medical records for review. They did not clarify what the denial reason was for. Therefore, we decided that the Plan has to pay for the Cologuard test provided to the enrollee on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric lift.
You asked the Plan to pre-approve an electric lift. You say that you are too heavy for your lift. The Plan denied your request. The Plan says that they do not cover duplicate or redundant durable medical equipment.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a manual lift. A manual lift serves the same purpose as an electric lift. Therefore, we decided that the Plan does not have to pre-approve an electric lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy (PT) (97750) to be provided by out of network provider.You asked the Plan to pre-approvePT. You say that your patient got accepted into a treatment for her tremors. It is the only place that does this treatment. The plan approved everyone at the University except the physician. Without approval your patient is unable to do treatment with any of the specialists. The University works closely with the physician on treating tremors.The Plan denied your request. The Plan says there are in-network physical therapists (PTs)who specialize in treatment of tremorsand Parkinson's at neuro rehabilitation unit. Your patient needs an evaluation by one of these in-network PTs as she has not exhausted all of thenetwork providers and they have not referred her to an out-of-networkproviderbecause they can perform PT. Thisproblem is not emergent sothemember must exhaust in-network providers as per the Plan's EOC.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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy (PT) (97750) to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
You asked the Plan to pre-approve continued CPAP use. The Plan denied your request. The Plan says that the enrollee is not compliant.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. We looked at the file and Medicare rules. The compliance report included with the file indicates the enrollee did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued CPAP use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient hospital stay provided from October 12, 2019 to October 16, 2019.
You asked the Plan to pay for an inpatient hospital stay. You say that this inpatient's stay was medically necessary as inpatient criteria for chronic obstructive pulmonary disease (COPD) includes an acute exacerbation accompanied by high-risk active acute comorbidity. The Plan denied your request. The Plan says that based on the clinical records provided this participant's care did not meet medical necessity criteria for acute inpatient hospital level of care. The participant's care needs could have been provided in an alternative care level such as observation status or an acute nursing facility. A short period of observation care and the participant could have returned home or to a sub-acute nursing facility or long-term nursing care (the participant's PACE interdisciplinary team) for out-patient observation and continued medical management.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. 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 inpatient hospital stay. Our reviewer says that the service was medically necessary. Our physician reviewer found the documentation supports that the requested services were necessary and reasonable to meet the participant's needs and to improve and maintain the participant's overall health status. The enrollee had worsening cough and shortness of breath despite appropriate outpatient management. There was evidence of exacerbation of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) for which appropriate outpatient management had failed to produce improvement. The requested services were not experimental, and the requested services were not cosmetic. 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 inpatient hospital stay have been met. Therefore, we decided that the Plan has to pay for an inpatient hospital stay provided from October 12, 2019 to October 16, 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia/Xgeva (denosumab).
You asked the Plan to pre-approve the denosumab treatments. You say that this is a medically necessary treatment due to the enrollee's use of aromatase inhibitors. The Plan denied your request. The Plan says that the enrollee does not have osteoporosis so this is not covered.
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 the denosumab treatments. Our reviewer says that the requested drug treatment is reasonable and necessary for this enrollee's condition. Our physician reviewer found Denosumab (Prolia) is FDA approved for treatment of bone loss (to increase bone mass) in females receiving aromatase inhibitor therapy for breast cancer. The patient has osteopenia and is on an aromatase inhibitor which can increase bone loss. The service is reasonable and 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 denosumab treatments have been met. Therefore, we decided that the Plan has to pre-approve Prolia/Xgeva (denosumab).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (pembrolizumab) injections.
You asked the Plan to pre-approve the Keytruda injections. You say that the enrollee should be covered for this treatment. The Plan denied your request. The Plan says that there is no need for this treatment as there has not been progression after platinum-containing treatment..
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 the Keytruda injections. Our reviewer says that the requested treatment is considered medically reasonable and necessary for this enrollee. Our physician reviewer found this review relates to a request for Keytruda for a 72 year old woman with urothelial cancer that has been treated with Cisplatin/Gemcitabine. She was not a surgical candidate. The office note of 3/30/20 states she was found to have progression of disease from a biopsy done during double J removal. Therefore she has progressive disease after Platinum based chemotherapy. Keytruda is FDA approved for the treatment of patients with locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 the Keytruda injections have been met. Therefore, we decided that the Plan has to pre-approve Keytruda (pembrolizumab) injections.
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: Favorable

We decided that the Plan has to pre-approvea right-sided lumbar transforaminal epidural steroid injection for enrollee.You asked the Plan to pre-approve a right-sided lumbar transforaminal epidural steroid injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that transforminal epidural steroid injections are only covered for certain indications.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 right-sided lumbar transforaminal epidural steroid injection. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has both thoracic and lumbar pain of long standing. The enrollee has an MRI which demonstrates pathology. The enrollee has documented pain and muscle weakness. The enrollee has failed conservative therapy including chiropractic, physical therapy, aquatherapy and medication trials.Therefore, the enrollee meets criteria for the requested injection 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 a right-sided lumbar transforaminal epidural steroid injection have been met.Therefore, we decided that the Plan has to pre-approve a right-sided lumbar transforaminal epidural steroid injection. 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/orsend 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 pay for the manual therapy techniques (97140) and the physical
therapy evaluation (97163) provided by an out of network provider on August 7, 2019.
You asked the Plan to pay for these services. You say that prior to receiving treatment, you called the doctor's
office to confirm that they accepted your insurance. The Plan denied your request. The Plan says you self-referred
out of network without prior authorization or a referral from your PCP.
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 has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan
does not have to pay for the manual therapy techniques (97140) and the physical therapy evaluation (97163)
provided by the out of network provider on August 7, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled services provided to the enrollee from July 1, 2019 to July 5, 2019.You asked the Plan to pay for skilled services provided to the enrollee from July 1, 2019 to July 5, 2019. You say that this claim should be paid.The Plan denied your request. The Plan says that Medicare billing criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were 9 pages in the file submitted. Other than the denial letter there were no medical records or specific explanation of the case itself. The Plan submitted an incomplete case file from which we are unable to substantiate the Plans denial. Therefore, we decided that the Plan has to pay forskilled services provided to the enrollee from July 1, 2019 to July 5, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to provide authorization for the inpatient admission requested on February 4, 2020.
You asked the Plan to provide authorization for the inpatient admission. You say that the enrollee was appropriate for inpatient admission as she was going to require several more days in the hospital beyond the date of the admission request. The Plan denied your request. The Plan says that the enrollee is considered stable and can just remain in observation status. There is no need to admit as inpatient. 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 inpatient admission. Our reviewer says that the documentation supports that criteria for inpatient admission were met in this case. Our physician reviewer found the enrollee is a 71 year -old female with a history of chronic respiratory failure on 21 of oxygen at home, pulmonary hypertension, hyperlipidemia, esophageal ulcer, bipolar disorder, anxiety and hypothyroidism. She presented to the ED on 2/2/20 with nausea, vomiting, chills, shortness of breath and a dry cough. Chest x-ray showed diffuse interstitial opacities consistent with pneumonia. The review indicates that the record showed that, at the time of the request for inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights which did occur as the enrollee remained in the facility until February 8, 2020 when deemed stable for discharge. 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 inpatient admission have been met. Therefore, we decided that the Plan has to provide authorization for the inpatient admission requested on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a network provider.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 fromout-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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral.