Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is not able to participate in and/or benefit from 15 hours of intensive rehab therapy per week.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of PT and OT but you do not require this or appear to have the tolerance for an intensive rehabilitation facility therapy program level 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a small volume nebulizer with compressor.
You asked the Plan to pre-approve a small volume nebulizer with compressor (E0570). You say that the
machine will help with your breathing. The Plan denied your request. The Plan says based on clinical
information the nebulizer 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 looked at the file and Medicare rules. The record does not show the enrollee's breathing is severely
impaired. Based on this information, we decided that Medicare rules for coverage of a small volume nebulizer
with compressor (E0570) have not been met. Therefore, we decided that the Plan does not have to pre-approve
a small volume nebulizer with compressor.
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 stroke, which was complicated by hemorrhagic conversion. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned off the ventilator. There is no evidence that the enrollee requires services that are not currently available. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (80061, 82044, 82570, 85025) provided on November 27, 2019.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized or emergent and were 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 forthe lab services (80061, 82044, 82570, 85025) provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist office visit. You say that you went to multiple in-network providers with no luck. You say that you would likeThe Plan denied your request. The Plan says there are still in-network providers available.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-approvespecialist office visit to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care provided on July 11, 2019.You asked the Plan to pay for nursing facility care. You say that insurance is eligible for this date of service. You say that claim should be reviewed.The Plan denied your request. The Plan says Original Medicare is responsible for payment.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 nursing facility care provided on July 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Diagnostic Digital Breast Tomosynthesis (77061) provided November 20, 2019.You asked the Plan to pay forthe Diagnostic Digital Breast Tomosynthesis. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says the CPT code used is not valid for Medicare purposes.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 77061 is not supported in the medical record. Specifically, the 2019 Year National Physician Fee Schedule Relative Value File, October Release, states that CPT 77061 is marked with an "I" and is therefore invalid for Medicare billing. Based on this information, we decided that Medicare rules for coverage of the Diagnostic Digital Breast Tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay fora Diagnostic Digital Breast Tomosynthesis (77061) provided November 20, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on October 8, 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 that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.

The file does not show that the provider
notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory
services are considered approved. Therefore, we decided that the Plan has to pay for the
laboratory services provided on October 8, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transthoracic Echocardiograph (TTE) (93306).
You asked the Plan to pre-approve the TTE. You say that the service is medically necessary. 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 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 the TTE. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has known coronary disease, mild valve regurgitation on a prior echocardiogram, no documented clinical cardiac change and a faint grade 1/6 apical systolic murmur that also is not documented to be changed. In this circumstance of a clinically stable patient only mild valvular regurgitation, recent normal ventricular function and no ischemia, the documentation does not support the medical necessity for repeat echocardiography. 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 TTE have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transthoracic Echocardiograph (TTE) (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe office visit and ultrasound provided on August 6, 2019.You asked the Plan to waive the cost share forthe office visit and ultrasound. You say that the specialist visit and ultrasound were not necessary. You say that you should be reimbursed.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to itsenrollees 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 $50 copayment for services obtained from a specialist and20% coinsurance for each Medicare-covered radiological diagnostic service.You have been asked to pay a total of $78.76 for the office visit and ultrasound. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The ultrasoundfalls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 cost share forthe office visit and ultrasound provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providethe SmartVest Airway Clearance System.You asked the Plan to providea high frequency chest wall oscillation device. You say that the medical records support symptoms that are as severe as the listed diagnoses.The Plan denied your request. The Plan says there is no diagnosis of bronchiectasis.The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases.The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to providethe SmartVest Airway Clearance System.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic garment (E0667).
You asked the Plan to pre-approve a pneumatic compression device and garment. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic garment (E0667).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that you would like reconsideration as it is the facilities responsibility to obtain authorization and the services were provided in good faith. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.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 September 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital visit provided on May 20, 2019.You asked the Plan to waive the copayment for the outpatient hospital visit. You say that you should not be responsible for the facility care. You say you went to see your primary care doctor. 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 $275 copayment for Medicare-covered outpatient hospital and observation services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for the outpatient clinic visit.You have been asked to pay a $81.44 copayment for the outpatient hospital visit. The outpatient hospital visit falls within the "Outpatient hospital 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 hospital visit provided on May 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe 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 thecase 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 3/11/20 after presenting to the emergency department and noted to be tachypneic. 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 with ventilator support with weaning trials, tracheostomy care, surveillance laboratory studies, blood transfusions as needed, tube feedings, 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 she 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPT code 27236-22-RT billed for date of service September 10, 2019.You asked the Plan to pre-approve CPT code 27236-22. You say that the medical records provided support the CPT code in dispute. You say that the 22 modifier was added because of the displaced femoral neck, requiring open reduction through a Smith-Peterson approach, which is more complex. You say that multiple implants were applied to the femur in an overlapping fashion and 75% more operative time was required than is typical for this procedure.The Plan denied your request. The Plan says the medical records do not include documentation of increased procedural services of an open treatment of femoral fracture, proximalend, neck, internal fixation or prosthetic replacement and, therefore, the CPT code in dispute cannot be verified.The Plan follows Medicare rules. Medicare rules say that procedures should be reported with the CPT code that describes the services performed.Weasked 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 CPT code 27236-22. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Our physician reviewer found that the records show routine femur fracture surgery with nothing complex to justify the use of the 22 modifier. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27236-22 have not been met. Therefore, we decided that the Plan does not have to pre-approveCPT code 27236-22-RT billed for date of service September 10, 2019