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

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the services required exceeds the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a recurrent stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that inpatient therapy is required to build mobility and strength.The Plan denied your request. The Plan says ongoing skilled services can be provided on an intermittent basis.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 physician reviewer found that the enrollee's current level of function is minimal assist with bed mobility, max assist for transfers, and moderate to max assist for activities of daily living. The enrollee is medically stable, with no evidence of need for supervision by a rehab physician, or acute rehab nursing care. His functional level and inability to tolerate therapies indicates that he cannot tolerate acute rehab. He may benefit from further physical and occupational therapy, but does not require an intensive therapy program. Therefore, an IRF admission is not medically necessary based on his current functional status and medical stability.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl for enrollee.You asked the Plan to pre-approve Fentanyl. You say that the fentanyl patch has worked the best to control the enrollee's pain.The Plan denied your request. The Plan says that Fentanyl to be taken at home is not covered under the Part B 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 Fentanyl for enrollee. Benefits for Fentanyl 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from August 29, 2019 to September 6, 2019.You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says prior authorization was not 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 did not pre-approve the inpatient services. 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 an inpatient services provided from August 29, 2019 to September 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for hospital discharge day management; 30 minutes or less (CPT Code) on August 27, 2019.You asked the Plan to pay forthe services. You say that you submitted a corrected claim to have the discharge date be August 27, 2019.The Plandenied your request. The Plan says that service code 99239 was billed and paid on the referring claim 820192410142011 for date of service August 26, 2019.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 did not prove that payment for the discharge services on August 26, 2019 was correct.Therefore, we decided that the Plan has to pay forhospital discharge day management; 30 minutes or less (CPT Code) on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on September 10, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say thatyou should not be responsible for the copayment. 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 forthe specialist office visit provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forlaboratory services provided on October 16, 2019.You asked the Plan to waive the deductible forlaboratory services. You say that the charge is out of line for a lab test. You say that you are on a fixed income and have never misused medication.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract withthe Plan says that your in-network deductible is $300, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Laboratory services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. ThePlan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to laboratory services. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on October 16, 2019. Therefore, we decided that the Plan does not have to waive the deductible forlaboratory services provided on October 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the documented skilled needs and required physical and occupational therapy do not meet the required intensity of service for admission to a Skilled Nursing Unity.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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.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-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex interspinous and/or interlaminar device for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies haven't proven that this device is helpful for treatment of this health problem.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 Medicarerules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with constant grade 2-6/10 low back pain radiating into the lower extremities. Functional limitations are noted in activities of daily living. Signs/symptoms are generally consistent with neurogenic claudication. The most recent imaging referenced in the medical records is dated 1/21/16 with findings of grade 1 anterolisthesis at L3/4 and L4/5, multilevel disc degeneration, advanced facet hypertrophy, and severe L3/4 bilateral neuroforaminal stenosis. She has reportedly failed greater than 6 months of reasonable and comprehensive conservative treatment. Under consideration is a request for the Vertiflex interspinous and/or interlaminar device at the L3/4 and L4/5 levels. FDA criteria have not been met to support the medical necessity of this procedure. This enrollee presents with severe spinal stenosis at the L3/4 level which is not a supported indication for the Vertiflex procedure. She is status post prior lumbar laminectomies at the L3/4 and L4/5 levels which is an FDA contraindication for this procedure. Her body mass index of 51 is an FDA contraindication for this procedure. Other contraindications have not been fully ruled out. There is no current imaging evidence relative to grading of the spondylolisthesis noted in 2016, and no documentation of flexion/extension x-ray findings. Additionally, this enrollee is 66 years old and there is no evidence of a DEXA scan ruling out the presence of osteoporosis. Therefore, this request for the Vertiflex interspinous and/or interlaminar device is not medically reasonable or necessary. 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Osteogenesis (bone growth) stimulator.You asked the Plan to pre-approvea bone growth stimulator. You say that this device is medically necessary.The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this device.The Plan follows Medicare rules. Medicare rules say that bone growth stimulators are covered for certain medical conditions, such as a long bone fracture.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 bone growth stimulator. Our reviewer says that the bone growth stimulator is not medically necessary at this time. Our physician reviewer found the use of bone stimulator for a C2 fracture is experimental. More research is needed. 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 bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approvean Osteogenesis (bone growth) stimulator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forsleep monitoring ofa patient (6 years or older) in a sleep lab with continued pressured respiratory assistance by a mask or breathing tube (95810). You asked the Plan to pay forsleep monitoring. You have a lot of trouble breathing while you sleep, which effects your blood pressure. You don't sleep as you have restless leg syndrome. You could be starved for oxygen as you wake up gasping.The Plan denied your request. The Plan says in this case, the requested 95810 is denied asit duplicates the diagnostic portion of the approved split night study. Due to the services being inclusive in the services provided by the approved 95811 this test (95810) is not medically necessary as it would duplicate the diagnostic portion of the approved spilt&#8208;night study.We have confirmed that code 95810 has a bundled relationship with code 95811. These codes are mutually exclusive. The Plan agreed to pre-approve code 95811 and therefore code 95810 is considered duplicative. Based on this information, we decided thatthe Plan does not have to pay forsleep monitoring of a patient (6 years or older) in a sleep lab with continued pressured respiratory assistance by a mask or breathing tube (95810).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the procedure is not covered.
The Plan must follow Medicare rules. The rules say that procedure code 43284 is non-covered. We looked at the file and Medicare rules. The services at issue are a LINX procedure described by code 43284. This code is denied by Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve a LINX procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 was admitted to acute care on 2/4/20 for pain in the abdomen. The enrollee was admitted for cholecystitis status post cholecystectomyand post op pulmonary embolism. On 2/18/20 she reports being very tired in therapy. She needs moderate assistance for bathing, minimal assistance for upper extremity dressing and lower extremity dressing, maximum assist for toileting x 2 and needs supervision for grooming. On 2/20/20 she had no complaints. She had rate controlled atrial fibrillation on IV heparin. In physical therapy (PT) on 2/20/20 she needed contact guard assistance for supine to sit. She ambulated 50 feet with an assistive device. She was noted to have decreased activity tolerance. The complexity of the enrollee's 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 the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee has decreased activity tolerance and fatigue and does not require this therapy on 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Diagnostic Mammogram (77066),
Diagnostic digital breast tomosynthesis (G0279), and an Ultrasound of the breast (76641) provided October 25,
2019
You asked the Plan to waive the copayment for the mammography services. You say that the copayment
should be waived for this preventative service. The Plan denied your request. The Plan says the copayment is
only waived if all services are rendered on the same date of service as the screening mammogram.
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 $100
copayment for Diagnostic Testing.
You have been asked to pay a $100 copayment for the mammography services. The mammography services
fall within the Diagnostic Testing 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 a
Diagnostic Mammogram (77066), Diagnostic digital breast tomosynthesis (G0279), and an Ultrasound of the
breast (76641) provided October 25, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs wound care, and has a safety issue of falling. The Plan denied your request. The Plan says there is no medical complexity that supports the need of a rehab physician three times a 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 physician reviewer found that the enrollee was admitted to acute care with advanced Parkinson's disease, and without new identified injury or reversible impairing condition. The enrollee's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, he does not require an intensive therapy program. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88305) provided to the enrollee on August 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says physicians may not bill or be separately paid for the technical and/or professional components of laboratory services performed in a facility setting.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 88305) provided to the enrollee on August 28, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 13, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that in most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on September 13, 2019