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

We decided that the Plan does not have to pay for the lab services provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was billed with the incorrect POS code.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on September 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care 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 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 requestto 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 you are medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) Physician or acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program with multidisciplinary approach. IRF admissionis 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 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.
Appeal type: Transportation
Decision: Favorable

We decided that the Planhasto pay forthe ambulance transportation provided on June 14, 2019.You asked the Planto pay forthe ambulance transportation. You say that this should be paidThe Plandenied your request. The Plansaysthatsince this transportation was from facility to facility, it must be included in the facility charges.The Plan must follow Medicare rules. Medicare rules say that for ambulance transportation with both the origin and the destination being a facility, separate payment can be made if the provider numbers of the two facilities are not the same.In this case, we do not have clearaccess to the provider numbers for the two facilities at issue. However, there is no evidence that both would be under the same provider number. As such, separate payment for the transportation is allowed under Medicare Part B.Therefore, we decided that the Planhas to pay forthe ambulance transportation provided on June 14, 2019.If the Plandoes 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/orsend 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 long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is 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 requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/26/20 for the treatment of massive brainstem cerebral vascular accident with subarachnoid hemorrhage/subdural hematoma. Her hospital course was complicated by acute respiratory failure requiring mechanical ventilation, hemothorax, symptomatic anemia, sacral pressure ulcer and arrhythmia.Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory care including ventilator management with tracheostomy care, telemetry with cardiovascular medication infusion, intravenous antibiotics, surveillance laboratory studies, tube feeding, sacral wound vacuum care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, porcelain or ceramic crown, and resin-based composite provided on July 22, 2019.
You asked the Plan to pay for the intraoral periapical x-ray, crown, and resin-based composite. You say that the dentist's staff member told you that your share of the cost would only be $417, but never told you that this was just an estimate. The Plan denied your request. The Plan says these services are not covered under your contract under any normal circumstances.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, porcelain or ceramic crown, and resin-based composite provided on July 22, 2019.
The Plan indicates that your grievance was processed under ID ST00432HJ to address your Quality of Care concerns. The Plan also states that a losing letter regarding your Quality of Care issues was mailed on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 core build up (D2950), a upper partial denture with a flexible base (D5225), and a lower partial denture with a flexible base (D5224).
You asked the Plan to pre-approve the core build up and the partial dentures. The Plan denied your request. The Plan says core build up and partial dentures with flexible bases are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 2 core build up (D2950), a upper partial denture with a flexible base (D5225), and a lower partial denture with a flexible base (D5224).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esbriet for the enrollee.
You asked the Plan to pre-approve Esbriet. You say that the refusal of Esbriet can increase the progression of fibrosis. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esbriet for the enrollee.
Benefits for Esbriet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide The Vest Airway Clearance System.
You asked the Plan to provide a high frequency chest wall oscillation system (E0483). You say that the enrollee has a respiratory condition and needs an airway clearance system. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of bronchiectasis.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to provide The Vest Airway Clearance System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sensor for a continuous glucose monitor (CGM).You asked the Plan to pre-approvethese services. You say that you need the sensors for a pump to work properly.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. The rules say that procedure code A9276 represents a sensor used with a non-therapeutic CGM. We looked at the file and Medicare rules. The item at issue is a sensor described by code A9276. This sensor is used for a non-therapeutic CGM and is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approvea sensor for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system and cup holder from your provider.
You asked the Plan to pre-approve a power wheelchair power seat elevation system and cup holder. You say that you need a power wheelchair with power seat elevation system and cup holder. The Plan denied your request. The Plan says a power wheelchair was approved but power seat elevation systems and cup holders are not considered medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system and cup holder from your provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan.You asked the Plan to pre-approvea CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested CT scan is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve a CT scan. Our reviewer says that the documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found there is no documentation from your doctor to show that you have signs and/or symptoms related to the body system that provides form, support, strength, and motion to your body. The documentation does not support that your symptoms are new or have changed. The documentation does not support notes thatshow you have failed to improve following a recent six-weektrial of doctor prescribed treatment and follow up with doctor to look at progress after six weeks. Therefore, you do not meet criteria for the requested 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 a CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea CT scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee manipulation procedure provided on September 16, 2019.You asked the Plan to waive the copayment forthe knee manipulation procedure. You say that you are appealing the copayment. 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 $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $125 copayment for the knee manipulation procedure. The knee manipulation procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you had met your $750 which means the copayment was applied to the surgical 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 forthe knee manipulation procedure provided on September 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 25, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes half an hour to an hour to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says 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 Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the member received these services during inpatient hospitalization and payment for this service would be included in the part-A DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 provided on April 18, 2019.You asked the Plan to pay for the drug testing. 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 G0480 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; 1-7 drug class(es), including metabolite(s) if performed.We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0480 provided on April 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the
enrollee's care could be provided at a lower level of care like in a long-term care facility or at home with home
health services.
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 the enrollee's condition does not
meet Medicare criteria for continued 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-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Testopel for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has hypogonadism and erectile dysfunction since 2014. He had placement of an inflatable penile prosthesis in 2016. He has been managed with testosterone replacement therapy since 2014 with testosterone pellets or intramuscular testosterone injections. The records support that Testopel is reasonable and medically necessary for the enrollee, as he has hypogonadism and has been effectively treated with the medication in the past. 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 been met. Therefore, we decided that the Plan has to pre-approve Testopel for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc injections for the enrollee.
You asked the Plan to pre-approve the requested injections. The Plan denied your request. The Plan says the enrollee is not using this medication to treat a confirmed osteoarthritis diagnosis.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation for the knee is only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested injections. Our physician reviewer found that the enrollee has knee pain. She does not have osteoarthritis on an MRI of her knee. The enrollee does not have degenerative changes of her knee on MRI. There is no proven efficacy in knee pain without osteoarthritis. Therefore, the requested procedure is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc injections for the enrollee.