Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio (Q5101).
You asked the Plan to pre-approve Zarxio. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried Neupogen (filgrastim) and Nivestym (filgrastim-aafi) as required by step-therapy rules.
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 Zarxio. Our reviewer says that criteria for coverage of Zarxio have not been met. Our physician reviewer found the Plan requires a trial of drug Neupogen (filgrastim) and Nivestym (filgrastim-aafi) before they will approve Zarxio. The documentation does not support that the enrollee has tried and failed Neupogen (filgrastim) and Nivestym (filgrastim-aafi), or that Neupogen (filgrastim) and Nivestym (filgrastim-aafi) 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 Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio (Q5101).
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 care can be safely received 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 the enrollee was admitted to the LTACH on December 3, 2019 for a prolonged course of IV antibiotics. The enrollee was and is not intubated/ventilated. The enrollee does not appear to require the level of services provided at a 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cortisone injection provided on September 18, 2019.You asked the Plan to waive the copayment forthe cortisone injection. You say that you satisfied a $35 specialist office visit copayment. You say that you shouldn't have to pay $200.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 a $290 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay $265.95, which is less than the standard$290 copayment for the cortisone injection. The cortisone injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cortisone injection provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe records provided show that the enrollee could receive the care at an alternate level of care, like a skilled nursing facility, or at home with home health.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 andnecessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for chronic respiratory failure. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term careneeds.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electronic analysis of a neurostimulator (95972) provided on
July 18, 2019.
You asked the Plan to pay for electronic analysis of a neurostimulator. 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 service billed.
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 95972 is electronic analysis of implanted neurostimulator
pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off
cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation,
detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health
care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse
generator/transmitter programming by physician or other qualified health care professional.
We asked our coder 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 electronic analysis of a neurostimulator. Our reviewer says
that CPT code 95972 is not supported. Our reviewer found the medical record does not contain evidence that
complex electronic analysis and programming of an implanted neurostimulator device was performed during
this episode of care. It cannot be confirmed that the services in the description of this CPT code were
performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of electronic analysis of a neurostimulator have not been met. Therefore, we
decided that the Plan does not have to pay for electronic analysis of a neurostimulator (95972) provided on July
18, 2019.
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 care can be provided in the current inpatient hospital.
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 the enrollee is currently undergoing treatment at an ACH for multi-system failure in the setting of advanced endometrial cancer. The enrollee was intubated/ventilated and quickly received a tracheotomy. She was started on hemodialysis and had a feeding tube placed. The enrollee is noted to have a poor prognosis and is thought to be appropriate for hospice. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 29, 2019 to July 28, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.
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 pay for the SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 29, 2019 to July 28, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for renal imaging (78709) and supplies (J1940 and A9562) provided on May 16, 2019.
You asked the Plan to pay for renal imaging and supplies. You say that these services were medically necessary. The Plan denied your request. The Plan says that these services require authorization.
The Plan must follow Medicare rules. Medicare rules say that the Plan must fully disclose and clearly specify all limitations and describe all POS benefits and cost-sharing. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of renal imaging and supplies have been met. Specifically, the Plan contract states that authorization rules "may" apply for these services. This statement is listed broadly for an entire category of services. It does not definitively state that authorization is required. The contract also does not say which specific services within the benefit category require prior authorization. We found that the statement directing the enrollee to customer service does not fulfill the requirement of full disclosure and specifying clear limitations. The language within the EOC does not meet Medicare criteria for full disclosure and clear specification of POS limitations. The contract is not clear that prior authorization is required for POS services. Therefore, we decided that the Plan has to pay for renal imaging (78709) and supplies (J1940 and A9562) provided on May 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a lithotripsy provided September 13, 2019.
You asked the Plan to waive the coinsurance for a lithotripsy. You say that you feel that you should only owe a $70 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for each outpatient hospital facility. You received a lithotripsy on September 13, 2019. The allowed amount is $3,260.00 and 20% of that is $652.00. You have been asked to pay the total coinsurance amount of $652.00 for a lithotripsy. A lithotripsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a lithotripsy provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and x-rays (72050 and 72070) provided on July 17, 2019 through August 14, 2019.
You asked the Plan to pay for the office visit and x-rays. You say that the doctor is listed as an in-network provider. The Plan denied your request. The Plan says this claim processed correctly per the Plan's 2019 EOC.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) and x-rays (72050 and 72070) provided on July 17, 2019 through August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for MRI provided on August 6, 2019.
You asked the Plan to waive the coinsurance for the MRI. You say that this amount is too high. 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 20% coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay $318.40 which is 20% of the allowed amount for the MRI. The allowed amount is $1,592.00. ($1,592.00 x 20% = $318.40). The MRI 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 coinsurance for the MRI provided on August 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission with you for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says federal regulations don't allow payments to a provider who has elected to opt out of the Medicare program.
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. You are a provider that has opted out of the Medicare program. The file shows that you have entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission with you for the enrollee.
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 the services could be provided in another setting.
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 the enrollee is currently undergoing treatment at an ACH, having initially been admitted with a septic wrist. The enrollee subsequently developed respiratory distress, which was managed with diuresis, supplemental oxygen and nightly BiPAP/CPAP. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider, on June 11, 2019.
You asked the Plan to pay for the hearing aids. You say that you were told by the provider's office that they accepted your insurance and that they are part of the network. The Plan denied your request. The Plan says hearing aids must be purchased; there is no coverage if hearing aids or related services are received from any provider other than hi HealthInnovations.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Hearing aids must be purchased through the provider; there is no coverage if hearing aids or related services are received from any provider other then the provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider, on June 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Thromboendarterectomy(35372 and 35302) and selective catheter placement (36246) provided on May 2, 2019.You asked the Plan to pay for the Thromboendarterectomy and selective catheter placement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes cannot be verified as 35372 and 35302 are inclusive to another CPT code and 36246 is not represented in the medical record.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 35372 is Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral.The CPT Code Manual definition of code 35302 is Thromboendarterectomy, including patch graft, if performed; superficial femoral artery.The CPT Code Manual definition of code 36246 is selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pay for the Thromboendarterectomy and selective catheter placement. Our reviewer says that according to CPT coding rules, endarterectomy procedures are reported by incision. In this case, one incision was made to perform an iliofemoral thromboendarterectomy. According to coding and NCCI rules, 35372 and 35302 are included in the iliofemoral thromboendarterectomy. Our reviewer found CPT code 36246 is not supported. The medical record does not contain evidence that selective catheter placement in a second order artery branch was performed during this episode of care.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Thromboendarterectomy and selective catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for Thromboendarterectomy (35372 and 35302) and selective catheter placement (36246) provided on May 2, 2019.