Persius/hicric huggingface dataset:
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 Plansaysongoing care can be provided at 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 is currently undergoing treatment at an ACH for bacteremia and pressure sores in the setting of a persistent vegetative state. The enrollee has a tracheotomyand feeding tube at baseline. 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 29,
2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the drug testing services have not been
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the
enrollee on April 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe radiationtherapy provided from May 1, 2019 to May 30, 2019.You asked the Plan to waive the coinsurance forthe radiation therapy. You say that the Medicare claim adjustments were less for services during the month of April 2019. The Plandenied 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 radiation therapy service. You have been asked to pay a total of $2,285.96 which is 20% of the allowed amount for the radiation therapy. The total allowed amount is $11,429.87. ($11,429.87 x 20% = $2,285.96). The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits.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 forthe radiation therapy provided from May 1, 2019 to May 30, 2019.Our decision is only about the May 2019 services. If you have any questions about prior month's billing, please contact the plan directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on March 27, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the claim was submitted with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on March 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from August 19, 2019 through August 26, 2019 by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on August 19, 2019 and discharged on August 26, 2019. The enrollee was asked to pay a $225 copayment per day from August 19, 2019 through August 23, 2019, days 1-5 of their inpatient stay. There were no copayment charges from August 24, 2019, day 6 of the enrollee's inpatient hospital care until their day of discharge August 26, 2019. Per the enrollee's contract there is a $225 copayment per day required for days 1-5. 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from August 19, 2019 through August 26, 2019 by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spine fusion for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee has severe stenosis. The Plan denied your request. The Plan says there is no evidence of instability that requires fusion.
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 requested services. Our physician reviewer found that there is no evidence of spinal instability, fracture, or tumor. Therefore, the requested services are not considered medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spine fusion for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe insulin provided on July 23, 2019.You asked the Plan to waive the coinsurance for the insulin. You say that you were told there would be no cost.The Plan denied your request. The Plan says that the claim 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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the insulin. The insulin falls within the Medicare Part B prescription drugs 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 forthe insulin provided on July 23, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 75mcg/Hr Fentanyl.
You asked the Plan to pre-approve the Fentanyl. You say that this drug is medically appropriate and has been effective in controlling the member's back and osteoarthritic joint pain. The Plan denied your request. The Plan says this medication falls under Part D coverage, not Part B.
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 75mcg/Hr Fentanyl.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 25, 2019 by an out of network (OON) provider.You asked the Plan to pay for the eye exam (92012). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet the criteria to receive care or services from an out of network provider without authorization.Medicare rules say that plans can require enrolleesto 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 isnot 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 forthese items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 25, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the visual field test (0379T).
You asked the Plan to pre-approve the visual field test.. You say that you are billing for the electronic reading not the device itself, therefore this is not a DME product. You bill as outpatient performed as an independent testing facility under minor lab diagnostics. The Plan denied your request. The Plan says this service does not meet the medically reasonably necessary criteria for coverage under Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on this information, we decided that Medicare rules for coverage of the visual field test. have not been met. Therefore, we decided that the Plan does not have to pre-approve the visual field test (0379T).
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 services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital 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 you are currently undergoing treatment at an acute care hospital (ACH) for a hemorrhagic stroke. You were intubated/ventilated and subsequently received a tracheotomy. It appears that you may already be off of the ventilator during the daytime. Whether or not complete ventilator liberation and decannulation are expected is unclear. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of SNF care.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 care. Our reviewer says that the enrollee does not meet criteria for coverage of SNF care. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. Additionally, she 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Optune Plus Transducers tumor treatment field therapy from Novocure Inc.You asked the Plan to pre-approvethe Optune Plus Transducers tumor treatment field therapy (E0766). You say that Optune is the most appropriate option for the enrollee at the present time.The Plan denied your request. The Plan says the enrollee does not meet criteria.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 Optune Plus Transducers tumor treatment field therapy (E0766). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found tumor treatment field therapy (E0766) is not covered for the treatment of newly diagnosed Glioblastoma Multiforme (GBM) because theTumor treatment field therapy was notinitiated within 7 weeks from the last dose of concomitant chemotherapyor radiotherapy, whichever is later; andthe beneficiary hasevidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria. Denyper LCD,as #3, #4 are answered no.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 Optune Plus Transducers tumor treatment field therapy (E0766) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Optune Plus Transducers tumor treatment field therapy from Novocure Inc.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for radiology services (CPT 73020) provided to the enrollee on October 21, 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 that this is a duplicate of a charge considered on a previous claim.
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 73020 is "Radiologic examination, shoulder." 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 reviewers says that Our physician reviewer found the records show bilateral single axillary views (CPT 73020) which do not appear to be duplicate charges and should be reimbursed. 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 been met. Therefore, we decided that the Plan has to pay for radiology services (CPT 73020) provided to the enrollee on October 21, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan of the skull to mid-thigh for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not necessary for stage 1 disease, per the NCCN guidelines.
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a grade II endometrial cancer, recurrent and her most recent CT of August, 2019 revealed abnormal findings with respect to the endometrium. As she has poor renal function she would not be a candidate for MRI or CT contrast which limits conventional imaging. Thus, in order to assess the pelvis including endometrium the best test would be PET/CT which would provide valuable information not available on CT or MRI without IV contrast. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve a PET/CT scan of the skull to mid-thigh for the enrollee.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 acute care hospital (ACH) for a groin hematoma/abscess in the setting of a prior femoral bypass. The enrollee is receiving wound care and antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there isno 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 (LTC) 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvea continuous glucose monitor. You say that you want a continuous glucose monitor so you don't have to prick yourself.The Plan denied your request. The Plan says the records do not show you check your glucose levels four or moretimes a day or that youareinsulintreated.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. You do not inject insulin or have an insulin pump. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 3, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 to the enrollee by an out-of-network provider on September 3, 2019.