Persius/hicric huggingface dataset:
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.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee entered the hospital on 3/2/20 for an elective total hip replacement. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Mayzent 2mg tablet medication.You asked the Plan to pre-approvethis medication.You say that this medication is medically necessary for the enrollee.The Plan denied your request. The Plan says this medication is not a covered benefit underthe member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Mayzent 2mg tablet medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a laproscopy (57425) and posterior colporrhaphy (57250) provided on
June 23, 2017.
You asked the Plan to pay for the laproscopy and colporrhaphy. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says that the documentation does not
support the CPT codes billed.
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 forwarded medical records to substantiate the denial of these
services. Therefore, we decided that the Plan has to pay for a laproscopy (57425) and posterior colporrhaphy
(57250) provided on June 23, 2017.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography.
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested transthoracic echocardiography is medically necessary. The Plan denied your request. The Plan says the requested transthoracic echocardiography is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 transthoracic echocardiography. Our reviewer says that the requested transthoracic echocardiography is not medically necessary. Our physician reviewer found the enrollee is with a history of dyslipidemia, remote smoking and aortic regurgitation. An echocardiogram 12/07/2018 reported 1-2+ aortic regurgitation, normal ventricular size and ejection fraction and no change from 2017. A clinic note dated 12/26/2019 documents no chest pain or dyspnea and a normal cardiovascular physical exam including a blood pressure of 128/70mmHg. Based on the records the enrollee has mild-to-moderate aortic regurgitation on echocardiography less than 2 years ago, no recent dyspnea, a recent normal cardiac physical exam including normal blood pressure with no widening of pulse pressure. In this circumstance of a clinically stable patient with no symptoms or findings of progressive aortic regurgitation and stable mild-to-moderate aortic regurgitation on serial echocardiograms
most recently less than 2 years ago, the records do not support the medical necessity for repeat echocardiography at this time. Current guidelines also do not consider repeat echocardiography appropriate in this setting of less than moderate regurgitation in a stable patient. 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 transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography.
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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest. The enrollee was intubated/ventilated. While the enrollee was able to be extubated, the decision was made to place an elective tracheotomy for airway protection. The enrollee was subsequently returned to a ventilator. The enrollee appears to have a poor long-term prognosis and Hospice is being considered. As LTACHs and ACHs are licensed to provide the same level of care, 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-approvelong term acute care hospital(LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that the provider was suggested by your Lyme disease support group and you have seen an improvement in symptoms.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior 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 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 forthe medical services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0482 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0482 is definitive drug testing, 15-21 drug classes.We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation of testing of 15-21 drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on March 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The provider submitted a claim for these services. The Plan previously paid for these services for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on March 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after March 5, 2020.You asked the Plan to pre-approvethe SNF services. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage. The enrollee can safely receive services at a lower level of careThe Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of servicecriteria for an inpatient basis in a skilled nursing facility setting.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services after March 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Testing (95999) provided August 15, 2019.You asked the Plan to pay fortrain of four testing. You say that services were medically necessary.The Plan denied your request. The Plan says train of four testing is bundled with the primary procedure.The Plan must followMedicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code train of four testing has a bundled relationship with code 95999 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for (95999) provided August 15, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring facility is out-of-network.
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 skilled nursing services provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on February 20, 2019.You asked the Plan to pay for train of four testing. You say that this was medically necessary.The Plan denied your request. The Plansays payment of this service is bundled into other services.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 find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures.   Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on February 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility services provided on July 23, 2019.
You asked the Plan to pay for the subsequent nursing facility services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 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 subsequent nursing facility services provided on July 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee has no skilled nursing needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.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 SNF services. Our physician reviewer found that that the enrollee continues to receive wound care. The enrollee requires oversight of his medical conditions and medication management. He has cognitive impairment and would not be expected to be able to adjust medications or self-monitor his medical conditions. He is at a dependent level of function and is unable to participate in rehabilitation therapies due to the degree of cognitive impairment. There are skilled needs, but they do not need to be provided on a daily basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Whole Exome Sequencing (81415, 81416, 81460).You asked the Plan to pre-approvethe Whole Exome Sequencing. You say that the sequencing is medically necessary to determine if a genetic disorder is responsible for the enrollee's condition.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are notmedically necessary are not covered. 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 Whole Exome Sequencing. Our reviewer says that based on current Medicare rules, coverage criteria for the sequencing requested has not been met. Our physician reviewer found there is no indication that the sequencing results will ultimately affect treatment. Additionally, there is no indication that the enrollee has cancer.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 Whole Exome Sequencing have not been met.Therefore, we decided that the Plan does not have to pre-approveWhole Exome Sequencing (81415, 81416, 81460).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior 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 did not pre-approve the service 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 physician's services provided on September 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you don't see the patient. You say that you complete lab work that is ordered by a physician. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider is also out-of-network.
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 lab work provided on October 21, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need to see this provider. The Plan denied your request. The Plan says that your request is not covered.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mesalamine tablets.
You asked the Plan to pre-approve Mesalamine. You say that the enrollee has been taking this medication for many years and needs it for stability of his inflammatory bowel disease. The Plan denied your request. The Plan says coverage of this Medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mesalamine tablets.
Benefits for Mesalamine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ECG provided on October 8, 2019.
You asked the Plan to waive the copayment for the ECG. You say that the service was performed in the doctor's office and not at the hospital. You say you were charged twice by the provider and the hospital. 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 $20 copayment for Medicare-covered outpatient diagnostic procedures or tests. You have been asked to pay a $20 copayment for the ECG. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed separately by the hospital for the ECG. 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 ECG provided on October 8, 2019.