Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary. The Plan denied
your request. The Plan says that your request is not medically necessary because your records show you have
not completed the necessary face-to-face evaluations to assure that this device meets but does not exceed your
need.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 a power scooter. Our reviewer says that
a power scooter is not medically reasonable and necessary in this case. You are not noted to have inability to
utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Our
physician reviewer found that your condition does not meet Medicare criteria for a power scooter.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does
not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis (L1833) provided to the enrollee on February 5, 2020.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules state that a knee orthosis is covered when there is recent injury to or surgical procedure on the knee or when knee instability is documented by examination of the beneficiary and objective description of joint laxity. There is no mention in the documentation of recent injury, surgical procedure or an objective description of knee instability.Therefore, we decided that the Plan does not have to pay fora knee orthosis (L1833) provided to the enrollee on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee.You asked the Plan to pre-approve a power scooter. You say that this is medically necessary.The Plan denied your request. The Plan says that they received no clinical information indicating the enrollee has difficulty performing normal activities of daily living and functional activities for self-care without significant difficulty.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power scooter. Our reviewer says that a power scooter is not medically reasonable and necessary for the enrollee. The patient is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a power scooter.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met.Therefore, we decided that the Plan does not have to pre-approve a power scooter for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on May 7, 2019.You asked the Plan to pay forthe services. You say that the stay was medically necessary.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. It appears that the enrollee had vital signs that daybut no procedure notes or post-operative notes on what was done are included in the appeal notes. There are no doctor's notes or procedure note from May 7, 2019. There is an inpatient admission June 17, 2019 through June 19, 2019 for your leg (left iliac artery) repair already approved. There needs to be an operation note or procedure note to show you had a procedure done on May 7, 2019 and this was not included in the appeal information.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on May 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on December 19, 2019.You asked the Plan to pay forthe ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee, complaining of foot pain was ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport.Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does nothave to pay forthe ambulance services provided on December 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging and to waive the coinsurance for a Medicare Part B drug provided on March 26, 2020.
You asked the Plan to waive the copayment for myocardial perfusion imaging and to waive the coinsurance for a Medicare Part B drug. You say that you cannot afford the charges. 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 a $100 copayment for nuclear medicine provided in a freestanding facility. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received myocardial perfusion imaging on March 26, 2020. Therefore, you are responsible to pay the $100 copayment. You received a Medicare Part B drug on March 26, 2020. The allowed amount is $26.04 and 20% of that is $5.21. The total amount you owe is: $105.21. You have been asked to pay the total amount of $105.21 for myocardial perfusion imaging and a Medicare Part B drug. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug 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 copayment for myocardial perfusion imaging and to waive the coinsurance for a Medicare Part B drug provided on March 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require daily skilled nursing or daily skilled therapy services at an inpatient level of care. We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 21, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on December 21, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Tecentriq injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that the plan has no contractual obligation to cover services that are not reasonable or necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has extensive small cell lung cancer, presumably of the lung. The use of this drug as planned with carboplatin and etoposide is considered a standard of care. The service is reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Tecentriq injection 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show that continued inpatient services are medically necessary. The file shows that the Plan has made reasonable efforts to obtain medical records, however, none were provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services (HCPCS G0482) provided to the enrollee on November 11, 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 the documentation submitted did not include a valid physician order/lab requisition or medical records. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." 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 the services at issue in this case were supported by the medical records. Our physician reviewer found the enrollee in this case is an 88 year old female diagnosed with long-term drug therapy and underwent comprehensive drug testing (HCPCS G0482). The order form includes confirmation testing for more than 22 drugs and metabolites to be tested including illicits, corresponding to the code submitted. Therefore, the records support the use of the
HCPCS G0482 code. 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 drug testing services (HCPCS G0482) provided to the enrollee on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 28, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that you do not have a need for daily skilled therapy or nursing services in an inpatient setting.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for injection services (HCPCS J3010) provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the injection. You say that his should be paid for. The Plan denied your request. The Plan says that Healthcare Common Procedure Coding System (HCPCS) code J3010 (1 Unit) remains 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 HCPCS code J3010 is "Injection, fentanyl citrate, 0.1 mg." We asked our coding 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 injection. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found per the table of Drugs and Biologicals, the route for fentanyl is IM, IV. 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 injection have been met. Therefore, we decided that the Plan has to pay for injection services (HCPCS J3010) provided to the enrollee on October 31, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient services provided on April 25, 2018. You asked the Plan to pay for the hospital outpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was not submitted timely. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the hospital outpatient services was not filed until February 29, 2020.. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital outpatient services provided on April 25, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided January
26, 2020 to February 24, 2020.
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 the Medicare criteria for continued SNF level of
coverage were not met.
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 January 26, 2020 to February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary for the enrollee.The Plandenied your request. The Plan says Medicare coverage criteria 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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.Based on the medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program.There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.Medicare coverage criteria are not met. 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.