Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health intensive outpatient program services.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not covered by the Plan.
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 services. Our physician reviewer found the health plan's denial of continued intensive outpatient mental health services appears appropriate. This enrollee did not require intensive outpatient mental health treatment as noted above as the enrollee was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Our physician reviewer was unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an intensive outpatient mental health treatment and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 pre-approve behavioral health intensive outpatient program services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the drug is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Neulasta. Our physician reviewer found that the requested use of Neulasta is not FDA-approved for the enrollee's diagnosis. The regimen does not meet criteria for high or intermediate risk. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an arthrocentesis, aspiration and/or injection of the major joint or bursa (20610) performed on December 3, 2020.
You asked the Plan to pay for an arthrocentesis, aspiration and/or injection. You say that the requested service was billed in compliance with guidelines. The Plan denied your request. The Plan says records do 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 20610 is "Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance."
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 an arthrocentesis, aspiration and/or injection. Our reviewer says that the requested procedure does not meet criteria for reimbursement in this case. Our reviewer found that the description in the medical record of the procedure performed does not meet criteria of CPT code 20610. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an arthrocentesis, aspiration and/or injection have not been met. Therefore, we decided that the Plan does not have to pay for an arthrocentesis, aspiration and/or injection of the major joint or bursa (20610) performed on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP machine to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a CPAP machine. You say that you need a specific kind of CPAP. You say that you would like approval to provide this equipment out-of-network. The Plan denied your request. The Plan says there are in-network providers available to provide the equipment that is needed.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a CPAP machine to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care (99223) provided on November 2,
2020
You asked the Plan to pay for the inpatient hospital care. You say that you would like this claim to be
reprocessed. The Plan denied your request. The Plan says the records did not support the service provided.
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 99223 is initial hospital care, per day, for the evaluation
and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 the inpatient hospital care. Our reviewer says that CPT code 99223 does not meet criteria for coverage or reimbursement consideration. Our physician reviewer found that the medical records provided do not include sufficient documentation to validate that an Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit that was performed on November 2, 2020. 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care (99223) provided on November 2, 2020
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (78813) provided on September 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
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 78813 is "Positron emission tomography (PET) imaging; whole body". 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 the services. Our reviewer says that the use of code 78813 is not supported by the records provided. Our reviewer found that the radiology report documents a positron
emission tomography (PET) and computed tomography (CT) whole body for attenuation correction. There is a more specific code to report for this procedure. Therefore, CPT 78813 would not be covered. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (78813) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a reline of complete lower denture (D5751) provided on March 31, 2021.
You asked the Plan to pay for a reline of complete lower denture. You say that you thought the service would be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every calendar year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a reline of complete lower denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service. Therefore, we decided that the Plan does not have to pay for a reline of complete lower denture (D5751) provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection for a wheelchair joystick (E2311).
You asked the Plan to pre-approve an electronic connection. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is 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 an electronic connection.
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee requires other types of proportional input devices (for example, mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (for example, sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (that is, for alternate control devices), other electronic devices (for example, control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed and groom independently supports that the enrollee can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection for a wheelchair joystick (E2311).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385) provided on April 5, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $150 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room or outpatient surgery services. There is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. However, any additional medical exams and other services provided during the visit may require copayments and/or coinsurance. You have been asked to pay a $150 copayment for the outpatient surgery provided. The service performed was considered as a diagnostic colonoscopy as a polyp was found and removed during this procedure. 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 the colonoscopy with lesion removal (45385) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the supply allowance for a therapeutic continuous glucose monitor (K0553) provided October 15, 2020.
You asked the Plan to pay for the supply allowance for a therapeutic continuous glucose monitor. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says that the documentation submitted does not meet the code criteria.
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supply allowance for a therapeutic continuous glucose monitor have been met. Therefore, we decided that the Plan has to pay for the supply allowance for a therapeutic continuous glucose monitor (K0553) provided October 15, 2020.
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: 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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen (14) additional OT visits.
You asked the Plan to pre-approve additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says fourteen (14) additional OT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 fourteen (14) additional OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on guidelines in Local Coverage Article: Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067) an updated reassessment of the enrollee's status and progress toward treatment goals would be needed to approve additional treatments beyond the ten additional occupational therapy treatments approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fourteen (14) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fourteen (14) additional OT visits.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approve acute inpatient rehabilitation facility (IRF) admission and services.