Persius/hicric huggingface dataset:
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/21/20 for sepsis due to sacral osteomyelitis, sacral stage IV ulcer and urinary tract infection. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include intravenous antibiotics, surveillance laboratory studies, tube feedings, wound care with dressing changes, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 the anesthesia services (01480, 76942, and 64445) provided on July 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for anesthesia services. You say that this should be covered. The Plan denied your request. The Plan says these 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 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 anesthesia services (01480, 76942, and 64445) provided on July 19, 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 the records provided support the need for LTACH care. The Plan denied your request. The Plan says there is no clear indication that the ventilator weaning process will be lengthy or complex. The Plan says that the enrollee's current medical needs can continue to be met at a lower level of care.
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 respiratory failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has recently been weaned from the ventilator. It is unclear if decannulation is planned. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time 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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/25/20 with respiratory failure due to pulmonary embolism, interstitial lung disease, and sepsis. The enrollee was intubated by emergency medical services. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including oxygen supplementation and nebulizer treatments, intravenous antibiotics, glucose control, intravenous steroids, surveillance laboratory studies, fluid balance, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: ER
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the office visit. We decided that the Plan does not have to waive the copayment for the clinic visit.
You asked the Plan to waive the copayments for the clinic visit and office visit. You say that you went to observation. You say that you shouldn't have additional copayments. The Plan says that the copayments applied correctly.
We decided that the Plan has to waive the copayment for the office visit.
Your contract with the Plan clearly says that you must pay a $0 copayment for physician services in a certified ambulatory surgery center or hospital outpatient department. The Plan says that you must pay a $20 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than $0. Therefore, we decided that the Plan has to waive the copayment for the office visit.
We also decided that the Plan does not have to waive the copayment for the clinic visit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each outpatient clinic visit. Therefore, we decided that the Plan does not have to waive the copayment for the clinic visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 24, 2019.
You asked the Plan to pay for the services. The Plan denied 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 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 medical services provided to the enrollee by an out-of-network provider on May 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pneumatic compression device provided on September 4, 2019.You asked the Plan to waive the coinsurance forthe pneumatic compression device. You say that the device does not work and you should not be responsible for the coinsurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay $460 which is 20% of the allowed amount for the pneumatic compression device. The allowed amount is $2,300. ($2,300 x 20% = $460). The pneumatic compression device falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forthe pneumatic compression device provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 30, 2019.
You asked the Plan to pay for the services. The Plan denied 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 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 medical services provided to the enrollee by an out-of-network provider on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 13, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections.
You asked the Plan to pre-approve the Prolia injections. You say that the records provided support the need for the drug in dispute. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested drug.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia injections. Our reviewer says that the enrollee does not meet the criteria for coverage of the requested drug. Our physician reviewer found the records do not support that the enrollee has tried and failed treatment of zoledronic acid. The records do not support that the enrollee has a history of an osteoporotic fracture. The records do not show that zoledronic acid would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like to be able to see your vascular surgeon. The Plan denied your request. The Plan says there are in-network providers available for these 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 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-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitoring system. You say that you have a hard time picking up things because your fingers hurt from finger stick testing. The Plan denied your request. The Plan says you are not insulin treated with three or more daily injections of insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a craniotomy (61320-78 and 61320-78-AS) provided on July 29, 2019.
You asked the Plan to pay for the craniotomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that these codes are not supported by the medical records submitted.
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 61320 is craniectomy or craniotomy, drainage of intracranial abscess; supratentorial. We asked our coder 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 craniotomy. Our reviewer says that the billing of CPT 61320 is supported. Our reviewer found upon removal of the bone flap purulent material was found in the epidural space and pus was identified in the ventricle, both of which would stand as evidence of an intracranial abscess. 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 craniotomy have been met. Therefore, we decided that the Plan has to pay for a craniotomy (61320-78 and 61320-78-AS) provided on July 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Logisticare mileage for routine transportation trips.
You asked the Plan to pre-approve additional Logisticare mileage for routine transportation trips. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.
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 36 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of additional Logisticare mileage for routine transportation trips have not been met. Therefore, we decided that the Plan does not have to pre-approve additional Logisticare mileage for routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip orthosis (CPT Code L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (CPT Code L2624) provided to the enrollee on August 2, 2019.
You asked the Plan to pay for the orthoses. You say that the orthoses The Plan denied your request. The Plan says the services are not supported by the records.
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 does not show that the telehealth service was provided in an authorized originating site. 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 hip orthosis (CPT Code L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (CPT Code L2624) provided to the enrollee on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 2, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were only charged by this one doctor during your stay. You say you were not an outpatient during your hospital stay and should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per specialist visit, including outpatient clinic visits. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Outpatient hospital services" benefit category. The medical record shows you were on observation and considered an outpatient. Therefore, the provider can bill for an outpatient specialist visit.
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 specialist office visit provided by on October 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 10, 2019 to August 7,
2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing care. You say that you are the only provider that accepts this insurance plan in the region. The Plan denied your request. The Plan says services from non-participating providers are
not covered under open access unless preauthorized.
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 June 10, 2019 to
August 7, 2019 by an out of network (OON) provider.