Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet criteria.
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 requested admission to a SNF meets criteria. Our physician reviewer found the enrollee was admitted on 01/27/2020 with a community-acquired pneumonia and exacerbation of chronic obstructive pulmonary disease. The enrollee lives alone in a single level residence and had been independent with use of a rolling walker at in-home to community distances. As of 01/31/2020 she required minimal assistance when transitioning from seated to standing. She required contact-guard assistance when ambulating 95 feet. She had a slow step through gait with decreased step length and required cueing for directions and to avoid objects. She was alert and cooperative and oriented. She had a good attention span and was able to follow commands with verbal cueing. She was receiving oxygen at 4 L via nasal cannula. The enrollee is status-post treatment for pneumonia and an exacerbation of chronic obstructive pulmonary disease and lives alone and had been able to ambulate independently at up to community distances. The enrollee requires oversight of her medical conditions and medication management. She is at risk for recurrent infections with chronic obstructive pulmonary disease exacerbation. The enrollee has not returned to her prior level of function. The enrollee requires physical therapy for mobility. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. The enrollee requires both daily skilled therapy and nursing services as she lives alone and is unable to perform transfers without assistance. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis. The enrollee had previously been able to function independently. She is participating in and benefiting from the therapy services being provided. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care being requested.
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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on April 4, 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 procedure code 99407 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 99407 is smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes. We find that CPT code 99407 is not supported in the medical record. Specifically, there is no documentation of more than 10 minutes of a smoking and tobacco use cessation visit. 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 pay for the services rendered to the enrollee on April 4, 2019.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee is with history of atherosclerotic cardiovascular disease, diabetes, chronic kidney disease and hypertension who developed osteomyelitis of the right foot and underwent a right below the knee amputation on 1/23/2020. She is now in a wheelchair and requiring minimum to moderate assistance with transfers. She requires maximum assistance with lower body dressing and bathing. Medical conditions are stable and incision site is "doing well." Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is no documentation of need for an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by out of network provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. The plan has in-network providers than could 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 medical services provided on September 27, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy (45378) provided by MNGI Endoscopy ASC, Inc. on October 14, 2019.
You asked the Plan to waive the copayment. You say that you were billed inappropriately for the services provided. The Plan denied your request. The Plan says the claim was paid and the appropriate cost sharing was applied for the services rendered.
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 $300 copayment for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center. You have been asked to pay a $300 copayment for the colonoscopy services provided. This procedure was an outpatient diagnostic colonoscopy performed in an ambulatory surgical center. 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 (45378) provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee on October 15, 2018 to October 16, 2018.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is payable per patient per hospital stay. We looked at the file and Medicare rules. The file shows that procedure code 99239 (hospital discharge) was previously paid by the Plan on a separate claim for the dates of service at issue. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee on October 15, 2018 to October 16, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. You say that the requested Zarxio is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail the preferred drugs, Neupogen and Nivestym first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zarxio. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with a diagnosis of Agranulocytosis secondary to cancer chemotherapy. He is receiving chemoradiotherapy for squamous cell carcinoma of the right buccal mucosa. The request is for Zarxio. The Plan requires a trial of Neupogen and Nivestym first before they will approve the requested drug, Zarxio. The documentation does not show that the enrollee has tried the Plan's preferred drugs. The documentation does not support that Neupogen and Nivestym would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and alveoloplasty (D7311).
You asked the Plan to pre-approve a complete upper denture (D5110) and alveoloplasty (D7311). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says a complete upper denture (D5110) is only covered once every five years. The Plan states you last received this item on January 11, 2018, which is less than 5 years ago. The Plan states alveoloplasty with code D7311 is not a covered benefit under Medicare or the Plan.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete upper denture (D5110) is not among those covered under this benefit at this time. The Plan contract clearly states you are covered for complete upper dentures once every five years. The file shows you last received this item on January 11, 2018, which is less than five years ago. Furthermore, the Plan's supplemental dental benefit does not cover alveoloplasty (D7311). Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and alveoloplasty (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle-foot orthosis (L1971) provided to the enrollee on March 13, 2019.
You asked the Plan to pay for the orthoses. 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 say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral ankle-foot orthosis (L1971) provided to the enrollee on March 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
September 4, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not want to pay
this charge since you only had an x-ray and the pain is still there. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment, up to a maximum, for emergency care.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows you received services during your emergency
room visit.
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 emergency room visit provided on September 4, 2019.
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 you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Ongoing medication management, wound care, and daily therapy can be provided at a skilled nursing facility. In this case a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection without imaging guidance.
You asked the Plan to pre-approve epidural without guidance. You say that you are unable to walk, maneuver around, and speech is declining. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Medicare requires fluoroscopic or Computed Tomography (CT) guidance when performing epidural steroid injections. The Plan also says that they would approve a new request for an epidural injection with guidance, so this denial is only because the epidural has been requested without guidance.
The Plan follows Medicare rules. Medicare rules say that epidural injections should be performed under fluoroscopic or CT guidance. 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 epidural without guidance. Our reviewer says that you do not meet the Medicare criteria for the requested epidural injection without guidance. Our physician reviewer found this procedure remains experimental and is not the standard of care. More research is needed to show the efficacy of epidural injections without imaging guidance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural without guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection without imaging guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided to the enrollee by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee should be evaluated at a medical facility. The Plan denied your request. The Plan says the enrollee's plan covers providers outside the network only when the medical needs cannot be met in the network.
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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided to the enrollee by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided from May 1, 2019 to May 7, 2019.
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed dates of service. The documentation does not include the time spent providing this service; therefore, the billed critical care evaluation and management code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided from May 1, 2019 to May 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that the admission is medically necessary. 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 enrollee was admitted to the hospital on November 25, 2019 with progressive weakness. She was transferred to a SNF after the admission for long term care. She needs supervision with bed mobility, minimal assistance with transfers from bed to wheelchair, and is non-ambulatory. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does 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 for the enrollee.