Persius/hicric huggingface dataset:
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 Plandenied your request. The Plansaysneeds can be met in a lower level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 seizure precautions, telemetry, intravenous antibiotics, hemodialysis, fluid balance with intravenous diuretics, surveillance laboratory studies, 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 he is currently receiving care. There are no required medicalservices 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-approveadmission 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 pay for diagnostic imaging provided on October 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for diagnostic imaging. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
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 diagnostic imaging provided on October 18, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Stelara first.
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 Entyvio. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is diagnosed with ulcerative (chronic) pancolitis with rectal bleeding. The enrollee has failed Lialda and developed antibodies to Humira. Entyvio has been requested. The plan has removed the requirement to try Remicade or Inflectra due to the issue with Humira. The provided medical records do not indicate that the enrollee has tried and failed the required drug, Stelara. 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic substrate crown and core buildup.You asked the Plan to pre-approve the dental services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary due to a lack of information -a periapical x-ray is needed.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 covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the provided radiographs reveal a previously restored tooth (#15) with minimal structural loss. There appears to be some defect in the restoration or tooth structure loss, but from the provided x-ray it appears to be readily restored with a conventional restoration. In this instance, there is no more than 25% total loss of structure visible and no indication there is a significant fracture that would compromise the tooth integrity. The previously existing restoration is small and without clinical notes indicating any other complicating factors there is no reason to believe a standard restoration would not be appropriate. Given the lack of significant loss of structure, there has been no adequate showing of a need for a full coverage crown. Cores are sometimes necessary if there is insufficient structure to retain a necessary crown. In this instance there is no need for a crown and therefore no need for a core.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic substrate crown and core buildup.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for practitioner visit. You say that this service was performed by a member of the facility's house provider group.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.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 September 24, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 19, 2019 through October 4, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that she did not improve while in the hospital. You say that the charge should be covered. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day, per admission, for days 1-5 at an in-network hospital.
The enrollee has been asked to pay a $1,125 copayment for the inpatient stay. ($225/day x first 5 days = $1,125). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 19, 2019 through October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe.You asked the Plan to pre-approve Prolia 60mg/ml syringe. 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.The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60mg/ml syringe have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established.Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy no coding test strips (A4253).
You asked the Plan to pre-approve Prodigy no coding test strips (A4253). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says they have approved a 3 month supply with no refills for the requested Prodigy no coding test strips to help transition to a preferred brand covered by the Plan.
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide documentation from your treating physician that the requested non-preferred brand, Prodigy no coding test strips are medically necessary. Based on this information, we decided that Medicare rules for coverage of Prodigy no coding test strips (A4253) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prodigy no coding test strips (A4253).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hemoglobin test provided on November 8, 2019. 
 
You asked the Plan to waive the copayment for the hemoglobin test. You say that you have never had to pay for this service before. The Plan denied your request. The Plan says the copayment 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 $10 for Medicare-covered laboratory tests.  
 
You have been asked to pay a $10 copayment for the hemoglobin test. The hemoglobin test falls 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 copayment for the hemoglobin test provided on November 8, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled therapy and daily skilled nursing services are not required.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do 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 only in a SNF. You do not have a complex wound care. You have been educated on ileostomy care and both your ileostomy and your catheter care do not require a SNF admission and can be managed at a lower level of care. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter you do not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on July 30,
2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of
consciousness and physiological status.
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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the
presence of an independent trained observer. Based on this information, we decided that Medicare rules for
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not
have to pay for moderate sedation services (99152) provided on July 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to enrollee on August 30, 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 procedure codes 11641 and 11621 are 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 11641 is excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm. The definition of code 11621 is excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm.We find that CPT codes 11641 and 11621 are not supported in the medical record. Specifically, the documentation does not indicate that an excision of malignant lesion of 0.6 to 1.0 centimeters on the face, ears, eyelids, nose, or lips was performed for the date of service to support code 11641 or that an excision of malignant lesion of 0.6 to 1.0 centimeters on the scalp, neck, hands, feet, or genitalia was performed for the date of service at issue to support code 11621. 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 for the services rendered to enrollee on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93000), office visit (99213) and a
federally qualified health center visit (G0467) provided on June 4, 2019.
You asked the Plan to pay for the electrocardiogram, office visit and federally qualified health center visit. You
say that you would like reconsideration as this claim was billed correctly. The Plan denied your request. The
Plan says CPT code 93000 has a status indicator of M for a service not billable to the MAC.
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 is not supported in the record. Specifically, per Medicare, CPT code 93000 has a status
code of M. This means that this code is not billable to the MAC. Based on this information, we decided that
Medicare rules for coverage of the electrocardiogram, office visit and federally qualified health center visit
have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93000),
office visit (99213) and a federally qualified health center visit (G0467) provided on June 4, 2019.
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 enrollee would benefit from the additional
physician and neurocognitive service provided by rehab to restore his neurocognitive function. The Plan denied
your request. The Plan says IRF admission is not medically necessary. A lower level of intensity such as skilled
nursing would be more appropriate.
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 based on review of the available records, the enrollee does not meet criteria for IRF
admission. The enrollee was medically stable with no evidence of need for supervision by physical medicine
and rehabilitation physician or needs acute rehab nursing care. The enrollee may benefit from further physical
therapy, speech and occupational therapy but does not require an intensive therapy program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services (11721 and 99335) provided on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON podiatry services. You say that the doctor is not responsible for authorization. The Plan denied your request. The Plan says OON services require 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 for the podiatry services (11721 and 99335) provided on September 11, 2019 by an out of network (OON) provider.