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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical extractions to be performed by an oral surgeon.
You asked the Plan to pre-approve two surgical extractions to be performed by an oral surgeon. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan states covered dental services must be performed by a participating general dentist. 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of two surgical extractions to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve two surgical extractions to be performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says they will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate 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 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. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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. 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating
provider on December 2, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this
coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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%
coinsurance for outpatient diagnostic tests/medical supply.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed
amount is $4,565.70. The total amount you are being asked to pay is $913.14 ($4,565.70 x 20% = $913.14). An
injection falls within the outpatient diagnostic tests/medical supply 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 coinsurance for an injection provided by a participating provider on December 2, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aprepitant.
You asked the Plan to pre-approve Aprepitant. You say that the enrollee has nausea and vomiting and is unable to keep solids or liquids down. You say that the requested drug is being requested to include in the enrollee's regimen in order to avoid further discomfort. The Plan denied your request. The Plan says the records do not show that the guidelines for coverage have been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aprepitant. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the requested drug is medically necessary for use with chemotherapy that causes nausea. The chemotherapy drug being used has a low-risk of nausea. It appears that the enrollee's nausea is from the cancer itself, and not the chemotherapy regimen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aprepitant have not been met. Therefore, we decided that the Plan does not have to pre-approve Aprepitant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas Therapy and subcutaneous injection of Nutri-
Pharmaceutical blend billed with codes 97112, 97032, 97016, 96372 x 4, J3415, J3411, J1955 and J3490 on
January 11, 2021.
You asked the Plan to pay for the Sanexas Therapy and subcutaneous injection of Nutri-Pharmaceutical blend.
You say that you would like reconsideration based on the records submitted. The Plan denied your request. The
Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The HCPCS/CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities.
The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas;
electrical stimulation (manual), each 15 minutes.
The HCPCS/CPT Code Manual definition of code 97016 is application of a modality to 1 or more areas;
vasopneumatic devices.
The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection
(specify substance or drug); subcutaneous or intramuscular.
CPT codes 97112, 97032, 97016, 96372 are not eligible for reimbursement consideration. Specifically,
outpatient physical therapy can only be paid for when rendered directly by a physical therapist, or by an nurse
practitioner when that nurse practitioner is allowed to perform physical therapy under State law.
The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.
The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg.
The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection.
The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm.
Payment for HCPCS/CPT codes J3415, J3411, J1955 and J3490 is not supported. Specifically, claims for
compounded drugs shall be submitted using a compounded drug code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas Therapy and subcutaneous injection of Nutri-Pharmaceutical blend have not been met.
Therefore, we decided that the Plan does not have to pay for the Sanexas Therapy and subcutaneous injection
of Nutri-Pharmaceutical blend billed with codes 97112, 97032, 97016, 96372 x 4, J3415, J3411, J1955 and
J3490 on January 11, 2021.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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-approve Ondansetron Tab.
You asked the Plan to pre-approve Ondansetron Tab. You say that the enrollee needs this drug for nausea. The
Plan denied your request. The Plan says the medication was denied due to not meeting criteria for Part B
coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We looked at the file and Medicare rules. The record shows this medication is not being initiated within 2
hours of chemotherapy and is not to be used as a full therapeutic replacement for intravenous anti-emetic
therapy. Based on this information, we decided that Medicare rules for coverage of Ondansetron Tab have not
been met. Therefore, we decided that the Plan does not have to pre-approve Ondansetron Tab.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health physical therapy.
You asked the Plan to pre-approve 8 home health physical therapy. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 8 home health physical therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 home health physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health physical therapy.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient services provided from November 14, 2020, to November 20, 2020.
You asked the Plan to pay for the inpatient care. You say that the enrollee was not stable for transfer on November 14, 2020, or any dates of service, and the Plan was notified. The Plan denied your request. The Plan says that the enrollee was stabilized on November 14, 2020, and the non-contracted provider did not notify the Plan or transfer the enrollee to a participating facility for continued care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the enrollee was not stable for transfer on November 14, 2020, or any of the subsequent dates of service. Our physician reviewer found that the enrollee presented to a non-contracted emergency department on November 14, 2020. The enrollee was then admitted as an inpatient and was treated with supplemental oxygen, antibiotics and medications. Once their condition stabilized and improved, the enrollee was discharged home on November 20, 2020. This reviewer has determined that the treating physician did document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient care have been met. Therefore, we decided that the Plan has to pay for the inpatient services provided from November 14, 2020, to November 20, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for respite care services provided October 1, 2020 to October 21, 2020.
You asked the Plan to pay for respite services. You say that this bill failed to be sent to the insurance. You paid because the nursing home did not accept Medicare. This was the only place that could take you. The Plan
denied your request. The Plan says the records show that the services received were listed as respite services and not skilled care. Medicare does not pay for custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for respite 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 service criteria 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 respite services have not been met. Therefore, we decided that the Plan does not have to pay for respite care services provided October 1, 2020 to October 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan Drops 0.0015% (CPT code J3490), for the
enrollee.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says Medicare guidance says non-injectable, self-administered drugs like Zioptan are
covered by the pharmacy (drug) benefit.

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 Zioptan Drops 0.0015%
(CPT code J3490), for the enrollee.

Benefits for the medication 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional skilled nursing visits.
You asked the Plan to pre-approve 6 additional skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 6 additional skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional skilled nursing visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance response and treatment (A0998) received March 15, 2021.
You asked the Plan to waive the copayment for the ambulance response and treatment. You say that the Plan should waive the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $250 copayment for Ambulance Services. You have been asked to pay a $250 copayment for the ambulance response and treatment. The ambulance response and treatment falls within the Ambulance 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 ambulance response and treatment (A0998) received March 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging (78452), the absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET) (78434), the cardiovascular stress test (93015), the Rubidium rb-82, diagnostic, per study dose, up to 60 millicuries (A9555), and the Regadenoson injection (J2785) provided on December 17, 2020.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 $110 copayment for each Medicare-covered radiological diagnostic service and a $30 copayment for each Medicare-covered non-radiological diagnostic service. Additionally, you pay a 20% coinsurance for each Medicare-covered medical supply and Medicare-covered Part B drug. Supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing. You have been asked to pay $505.65 which includes a ($110 copayment x 2= $220) for the Medicare-covered radiological diagnostic services, a $30 copayment for the non-radiological diagnostic service, a $208.30 coinsurance (Plan allowed amount of $1,041.50 x 20%) for the Medicare-covered medical supply (chemical agent) for the diagnostic procedure, and a $47.35 coinsurance (Plan allowed amount of $236.76 x 20%) for the Medicare Part B drug provided. 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 for the myocardial perfusion imaging (78452), the absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET) (78434), the cardiovascular stress test (93015), the Rubidium rb-82, diagnostic, per study dose, up to 60 millicuries (A9555), and the Regadenoson injection (J2785) provided on December 17, 2020.