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

We decided that the Plan does not have to pay for surgical laparascopy (CPT 43922) provided to the enrollee on October 30, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says CPT 49322 is not supported by the medical records submitted.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 49322 is "surgical laparoscopy, with aspiration of cavity or cyst (ovarian cyst) (single or multiple)."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the he medical records provided  do not include documentation of a Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) being performed on October 30, 2019, therefore this service cannot be verified.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 Plan does not have to pay for surgical laparascopy (CPT 43922) provided to the enrollee on October 30, 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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 you had recently been in the hospital with gram negative sepsis related to a urinary tract infection. You were treated with intravenous fluids and Midodrine for the low blood pressure and mirtazapine for poor appetite. You were seen by nephrology and cardiology while inpatient. Your condition has improved. Imaging studies revealed no acute conditions. Labs have essentially normalized. Physical therapy and occupational therapy was ordered, though no detailed therapy notes were available for review. The documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may benefit from further physical therapy and occupational therapy, the documentation does not support that you required an intensive rehabilitation therapy program. Your needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 enrollee requires long term acute care which is best provided in an LTACH. The Plan denied your request. The Plan says the enrollee's needs can be met by remaining in the current facility.

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 respiratory support with high flow oxygen, intravenous morphine, surveillance laboratory studies, Foley care, skin care, 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. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an upgraded presbyopia-correcting intraocular lens (IOL) provided on July 30, 2019.You asked the Plan to pay for an upgraded presbyopia-correcting IOL. You say that you should be reimbursed the full cost of this surgery.The Plan denied your request. The Plan says this processed correctly.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers standard IOLs. For an additional fee, you may request the insertion of a presbyopia-correcting IOL in place of a conventional IOL following cataract surgery. You will pay an additional fee for non-conventional IOLs recommended or directed by your physician. You are responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. We looked at the file and the Plan's rules. The file shows that the Plan has paid the cost of the standard IOL and you are responsible for the additional cost of the presbyopia-correcting IOL.Based on this information, we decided that the Plan's rules for coverage of an upgraded presbyopia-correcting IOL have not been met.Therefore, we decided that the Plan does not have to pay for an upgraded presbyopia-correcting intraocular lens (IOL) provided on July 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services provided to the enrollee on November 15, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the claim denied because there was another claim for the same date of service for an observation services rendered by another provider.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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found billing of CPT 99285 requires a comprehensive history, comprehensive examination and medical decision making of high complexity. The medical decision making in this case was not of high complexity. The enrollee had a very straightforward complaint, which generated a standard evaluation. Furthermore, the enrollee appears to have been clinically stable and without a problem that posed an immediate threat to his life or function. The billing of CPT 99285 is not supported.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 Plan does not have to pay for emergency department services provided to the enrollee on November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daliresp 500mcg tablet.You asked the Plan to pre-approve Daliresp 500mcg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 Daliresp 500mcg tablet.Benefits for Daliresp500mcg tablet 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services (90999) provided from January 2, 2020 to February 1, 2020.You asked the Plan to waive the coinsurance for dialysis services. You say that you were told these services would have a $10 copayment.The Plan denied your request. The Plan says these services processed 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 a 20% coinsurance for each Medicare-covered renal dialysis service. You have been asked to pay $59.80 ($299 allowed amount x 20% = $59.80) for each dialysis service you received. 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 dialysis services (90999) provided from January 2, 2020 to February 1, 2020.Your complaint about being told the wrong copayment amount is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99213 and 99214) and osteopathic treatment (98928) provided by providers who have opted out of Medicare from November 19, 2019 to January 28, 2020.You asked the Plan to pay for office visits and osteopathic treatment. You say that you were told these providers were in-network.The Plan denied your request. The Plan says these providers have opt-ed out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by providers who have opted out of the Medicare program. The file shows that these providers entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for office visits (99213 and 99214) and osteopathic treatment (98928) provided by providers who have opted out of Medicare from November 19, 2019 to January 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency medicine services (CPT 92950) provided to the enrollee on November 30, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.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 92950 is "Cardiopulmonary resuscitation (eg, in cardiac arrest)."We find that CPT code 92950 is not supported in the medical record. Specifically, the code is not supported as it was billed with a secondary diagnosis code as the primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for emergency medicine services (CPT 92950) provided to the enrollee on November 30, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT Scan of the thorax (71250).You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because the CT Scan is medically necessary.The Plan denied your request. The Plan says that the records do not show that the member has a 30 pack a year smoking history.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT Scan. Our reviewer says that a low-dose chest CT scan for the purpose of lung cancer screening is reasonable and medically necessary. Our physician reviewer found the member is within the appropriate age range (63 yoa), has quit smoking within the last 15 years, and according to an addendum to the medical record, has a history of more than 30 pack-years.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 CT Scan have been met.Therefore, we decided that the Plan has to pre-approve a CT Scan of the thorax (71250). We decided that the Plan has to pre-approve a CT Scan of the thorax (71250).You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because the CT Scan is medically necessary.The Plan denied your request. The Plan says that the records do not show that the member has a 30 pack a year smoking history.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 the CT Scan. Our reviewer says that a low-dose chest CT scan for the purpose of lung cancer screening is reasonable and medically necessary. Our physician reviewer found the member is within the appropriate age range (63 yoa), has quit smoking within the last 15 years, and according to an addendum to the medical record, has a history of more than 30 pack-years.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 CT Scan have been met.Therefore, we decided that the Plan has to pre-approve a CT Scan of the thorax (71250). 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says this is not covered under Part B.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.Benefits for this drugmay 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 Euflexxa. Our physician reviewer found that the enrollee has osteoarthritis of the knee. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs.  The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve900 diabetic test strips for 90 days.You asked the Plan to pre-approve the test strips. You say that the strips are medically necessary.The Plan denied your request. The Plan says the number of test strips provided meets the enrollee's needs.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 test strips. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not substantiate any reason why the enrollee needs the number of test strips (900) requested.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 test strips have not been met.Therefore, we decided that the Plan does not have to pre-approve900 diabetic test strips for 90 days.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab for the enrollee.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided by a not certified for Medicare provider.You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the provider is ineligible to bill Medicare.The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The file shows the durable medical equipment was provided by a provider that has not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met.Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided by a not certified for Medicare provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion surgery.
You asked the Plan to pre-approve spine surgery. You say that the enrollee is in great pain and is unable to ambulate. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not completed and failed 2 types of conservative care.
The Plan follows Medicare rules. Medicare rules say that lumbar spinal fusion surgery may be considered medically necessary for certain, specific indications. 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 spine surgery. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested spinal surgery. Our physician reviewer found there is no spinal instability. More conservative measures such as physical therapy are needed. Fusion surgery is not medically necessary 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 spine surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion surgery.