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

We decided that the Plan does not have to pre-approve CT, thorax; without contrast material (CPT Code 71250).
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Review of the records show these Medicare requirements are not met because: the enrollee is 79 years old. The rules say for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: Age 55 - 77 years. Therefore, we decided that the Plan does not have to pre-approve CT, thorax; without contrast material (CPT Code 71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that it wouldn't be safe to send the member home. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at home with home health care, or in a long-term care setting.

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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81292, 81298, 81317) provided August 2, 2020 to August 20, 2020.
You asked the Plan to pre-approve the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the procedure is not a covered procedure.
The Plan must follow Medicare rules. Medicare rules say that genetic testing using Next Generation Sequencing must be FDA approved in order to be covered. We looked at the file and Medicare rules. The TEMPUS testing performed is not currently FDA approved. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81292, 81298, 81317) provided August 2, 2020 to August 20, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the COVID-19 testing received on November 15, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you were tested for COVID-19 because you were in close contact with someone with COVID-19. The Plan denied your request. The Plan says that the services are not covered.
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 has not provided a Medicare-approved source to show that COVID testing should not be covered in this case. Therefore, we decided that the Plan has to pay for the COVID-19 testing received on November 15, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for a continuous glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee cannot tolerate three (3) hours of therapy a day and that is hindering their ability to regain functional independence. The Plan denied your request. The Plan says the stay 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for shortness of breath and was treated for pneumonia. He had biopsy of a new lung mass. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services.

You asked the Plan to waive the copayment for these services. You say that you should only be liable for a
$175 copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
copayment for Medicare-covered outpatient hospital and observation services.

Review of the file shows that you received outpatient surgical services at an outpatient hospital facility. You have been asked to pay a $275 copayment for these services. These services fall within the Medicare-covered outpatient hospital and observation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for office visits. You say that the Plan is treating the deductible as though you were not covered. The Plan says that the deductible amounts you are being charged are correct.
We decided that the Plan has to waive the deductible for the office visits.
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 says that the deductible applies to outpatient mental health services, but your contract with the Plan also says that the deductible does not apply to in-network physician specialist services. These visits were performed by an in-network psychiatrist, which is a type of physician specialist. Therefore, your contract with the Plan does not clearly state whether these visits apply to the deductible or are excluded from the deductible.
We looked at your contract with the Plan. The Plan contract does not clearly say whether the deductible applies to these in-network psychiatry office visits. This means that the Plan did not follow Medicare rules for disclosure of cost-sharing information. Therefore, we decided that the Plan has to waive the deductible for office visits.
We also decided that the Plan does not have to waive the copayments for the office visits.
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 copayment for each in-network covered outpatient mental health care visit. There were 2 visits, resulting in a total copayment amount of $40. Therefore, we decided that the Plan does not have to waive the cost-sharing for office visits.
Therefore, we decided that the Plan has to reduce your total cost-sharing responsibility for these claims from $262.56 to $40.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 2, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 psychotherapy services provided on January 2, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve spinal cord stimulator trial (63650x2).
You asked the Plan to pre-approve spinal cord stimulator trial. You say that it would be prudent to proceed with a spinal cord stimulator trial to see if you could get better coverage of his complex regional pain syndrome. The Plan denied your request. The Plan says that under Medicare guidelines the request is not medically necessary.
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 spinal cord stimulator trial. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the requested stimulator is being used as a late resort in a multi-modality pain treatment program where other therapies have not been successful. The enrollee has had a psychological evaluation. While the denial issued by the plan is for both the stimulator and the trial, the letter from the prescriber clearly indicates the request is for the trial. Therefore, the criteria for the National Coverage Determination for the stimulator trial are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator trial have been met. Therefore, we decided that the Plan has to pre-approve spinal cord stimulator trial (63650x2).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. The Plan says that either the services performed, the servicing provider, or the number of visits billed do not match what was approved on the authorization.
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 the medical services provided on August 27, 2020 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 Libre 14 day sensor kit.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor kit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for planned cervical spine surgery. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the midazolam hydrochloride injection (J2250 x 22) provided on April 8, 2020.
You asked the Plan to pay for the midazolam hydrochloride injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate code which should be billed for the services performed.
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 J2250 is injection, midazolam hydrochloride, per 1 mg. 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 midazolam hydrochloride injection. Our reviewer says that CPT code J2250 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not document that Midazolam Hydrochloride was given prior to surgery. Documentation supports Lidocaine 1% 6 ml and Dexamethasone 10/mg/ml 1 ml was given. 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 midazolam hydrochloride injection have not been met. Therefore, we decided that the Plan does not have to pay for the midazolam hydrochloride injection (J2250 x 22) provided on April 8, 2020.