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

We decided that the Plan does not have to pay for the electrocardiogram services (93000, 99214) provided on August 15, 2019 by an out of network provider. You asked the Plan to pay for the electrocardiogram. You say that the services should be covered. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There are in-network providers that can provide the services at issue. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the electrocardiogram services (93000, 99214)  provided on August 15, 2019 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee is now mostly CGA-to-supervised for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including home health care services). The enrollee's vital signs are stable. SNF is not medically 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond February 2, 2020.You asked the Plan to pre-approvethese services. You say that you need more therapy.The Plan denied your request. The Plan says the continued services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNFwhen 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to the SNF on January 20, 2020 and received oral medications and had stable vital signs. You received occupational therapy and need assistance with walking short distances with a walker. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond February 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the Enrollee on
September 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered to the Enrollee on September 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190)
provided to the enrollee on August 14, 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 enrollee received the services in the facility during inpatient hospitalization, and payment for
this service would be included in the part-A DRG payment to the facility.
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 99190 is "Assembly and operation of pump with
oxygenator or heat exchanger (with or without ECG and/orpressure monitoring); each hour."
We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is
included in the payment to the facility. 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 oxygenator
assembly and operation services (CPT 99190) provided to the enrollee on August 14, 2019.
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-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with sepsis. The enrollee was intubated/ventilated, but it appears that she is no longer 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.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lower spinal canal for the enrollee.You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no change in exam, and no evidence in the notes of cord compression. The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found a diabetic patient with prior history of epidural abscess presented with bladder incontinence and abnormal reflexes. Even without significant change in symptoms the prior history, the recent fall and an abnormal neurological exam qualify this patient for MRI due to presence of several red flags. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lower spinal canal for the enrollee. 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 pay for the home infusion supplies (A4216, A4221, A4222, J1250,
J1644) provided on August 7, 2019 to August 13, 2019 by an out of network provider.
You asked the Plan to pay for the home infusion supplies. You say that the services should be covered. The
Plan denied your request. The Plan says the items were provided out-of-network. They were not emergent or
preauthorized and the plan has in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the home infusion supplies (A4216, A4221,
A4222, J1250, J1644) provided on August 7, 2019 to August 13, 2019 by the out of network provider.
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 for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met.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 the complexity of the 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 medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee does not require this 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection (E2311) expandable Controller (E2377) and expandable controller harness (E2313).
You asked the Plan to pre-approve the upgraded electronics. You say that these electronics are necessary for the enrollee to safely operate a power wheelchair for participating in completing mobility related activities of daily living. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary.
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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requests are convenience items and cannot be considered medically necessary, as they do not serve to enhance the function of the power mobility device or will enhance this member's ability to perform mobility and mobility related activities of daily living tasks. As such, these accessories are not medically 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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection (E2311) expandable Controller (E2377) and expandable controller harness (E2313).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral breast MRI for breast cancer screening.
You asked the Plan to pre-approve the screening MRI of the breasts. You say that you have dense breasts and
need this imaging in order to screen for breast cancer. The Plan denied your request. The Plan says this is not
covered for screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
This MRI is requested for screening purposes. While Medicare does allow coverage for screening
mammograms, MRIs are not among the types of covered breast cancer screenings. Therefore, we decided that
the Plan does not have to pre-approve a bilateral breast MRI for breast cancer screening.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that the SNF will provide the level of care you need. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you presented to the emergency department on January 25, 2020 with worsening confusion. You had stable vital signs and underwent tumor excision. You received physical therapy in the hospital and need assistance with mobility, including walking 65 feet. You need varied assistance with activities of daily living. You do not have skilled nursing needs. You have skilled therapy needs, but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies provided on April 18, 2019.

You asked the Plan to pay for the ambulance supplies (A0999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says payment for ambulance supplies are included in the payment rate for the transport.

The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the general ambulance service and included in the transport payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies (A0999) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance supplies provided on April 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on May 16, 2019.You asked the Plan to pay forthe orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.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 orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in thiscase, according to the coverage criteria established by the LCD. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a back complaint and a physical examination of the back.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided to the enrollee on May 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan injection services.You asked the Plan to pre-approveHyalgan injection services. You say that the requested drug is medically necessary for treatment of the enrollee's knee pain.The Plan denied your request. The Plan says the enrollee has not tried and failed prior conservative treatment for her condition. The plan says that the requested drug is subject to step therapy.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 Hyalgan injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found Orthovisc was administered on January 22, 2020. The documentation does not support that Monovisc would likely be less effective or would have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan injection services have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan injection services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 25, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered in full. 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 $10 copayment for diagnostic lab services and diagnostic procedures and tests. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF
admission is not medically necessary.
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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that this enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment. The enrollee does not have a complex
wound care or other SNF level skilled nursing need. This enrollee's functional status does not require skilled
therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require
these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a
practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing
facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission.