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

We decided that the Plan does not have to pre-approve a CT scan of the chest.  You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 was correct 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 a provider progress note states the enrollee had a chest computed tomography study in June 2019 demonstrating a left lower lobe infiltrate. Review of a computed tomography report dated 6/27/19 remarks "minimal bibasilar subsegmental atelectasis or scar with otherwise clear lungs, no adenopathy" A progress note in October documents no respiratory complaints or abnormalities identified on physical examination. There is no concerning findings or differential diagnosis outlined in the reviewed records. Without the support of the documentation, medical necessity cannot be determined. Therefore, the enrollee does not meet criteria for the requested CT scan. 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-approve a CT scan of the chest.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors but was pleasant and cooperative. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, delusions or hallucinations or aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were
reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. I am 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 patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 12, 2019 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being pleasant and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99306) provided on July 16, 2019 by
the out of network provider.
You asked the Plan to pay for nursing facility care. You say that you submitted additional documentation
requested to review for the maximum allowed amount. The Plan denied your request. The Plan says the
medical records submitted do not meet urgent/emergent criteria. The Plan says there is no documentation of
prior authorization and there are services available in-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 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 nursing facility care (99306) provided on July 16,
2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on August 29, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 29, 2019. The Plan denied your request. The Plan says the doctor is a non-participating provider and the referring provider is also a non-participating provider. The Plan says it did not authorize any services for either doctors who are both non-participating providers. The Plan also says that services were not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services.
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 an office visit (99215) provided on August 29, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on September 18, 2019.
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that this was only a follow-up visit and you disagree with 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 $325 copayment for non-surgical visits provided in an outpatient clinic for outpatient hospital services. You have been asked to pay the allowed amount of $118.94, which is less than the $325 copayment for an outpatient hospital visit. An outpatient hospital visit falls within the outpatient hospital services 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 an outpatient hospital visit provided on September 18, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve surgical excision of a foot lesion.
You asked the Plan to pre-approve foot surgery. You say that your condition is getting worse, your feet are swollen, and you cannot wear socks or put your foot up. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because there is no documentation that you have tried conservative treatments.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve foot surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found it is well documented that you have a painful lesion on your foot. This condition is considered to be a malformed portion of your foot. Excision of a lesion is considered safe and effective and is not mainly for the convenience of the patient or physician. In this case, you note pain to the affected area. This operation is not considered experimental and will meet your medical needs. Therefore, the requested surgical excision of a lesion on your foot is medically reasonable and 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 foot surgery have been met. Therefore, we decided that the Plan has to pre-approve surgical excision of a foot lesion.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery (20931, 20937, 22612, 22630, 22633, 22840, 22853, and 61783).
You asked the Plan to pre-approve spinal surgery (20931, 20937, 22612, 22630, 22633, 22840, 22853, and 61783). You say that the requested spinal surgery is medically necessary. The Plan denied your request. The Plan says the requested spinal surgery 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 spinal surgery (20931, 20937, 22612, 22630, 22633, 22840, 22853, and 61783). Our reviewer says that the requested spinal surgery is not medically necessary. Our physician reviewer found the enrollee is with central/lateral/foraminal stenosis with neurogenic claudication. The plan approved CPT codes 63047-Laminectomy and 63048-Laminectomy. Based on the documentation provided, there is no medical need for spinal fusion. There is no documented spinal instability, fracture, or tumor. Spinal fusion is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery (20931, 20937, 22612, 22630, 22633, 22840, 22853, and 61783) have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery (20931, 20937, 22612, 22630, 22633, 22840, 22853, and 61783).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a travel-sized Continuous Positive Airway Pressure
(CPAP) device.
You asked the Plan to pre-approve travel-sized CPAP device. You say that you travel a lot and this CPAP
device is medically necessary for you. The Plan denied your request. The Plan says the denial of authorization
for this item is correct, because you have already been provided with a CPAP device and this travel-sized
CPAP device is not medically necessary.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
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 travel-sized CPAP device. Our reviewer
says that you do not meet the Medicare criteria for the requested oxygen equipment. Our physician reviewer
found you were provided with a CPAP device in October, 2019 and have been using this device with good
compliance and improvement in symptoms. Medicare does not cover duplicate devices and does not cover
equipment specifically for travel outside of the home. A travel-sized CPAP device is considered to be a
convenience item which duplicates the purpose of the device already provided. Therefore, this item is not
covered 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 travel-sized CPAP device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a travel-sized Continuous Positive Airway Pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no report of a trial of physical therapy for four weeks without it helping.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that you have not had an adequate trial of physical therapy or other conservative approaches. The
requested procedure is deemed not medically reasonable or necessary 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an epidural injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physician services provided from June 28, 2019 to August 26, 2019.
You asked the Plan to waive the coinsurance for physician services. You say that you were told that you would
owe anywhere from $0 to $150 and disagree with 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 45%
coinsurance for out-of-network physician/practitioner services, including doctor's office visits.
You received physician services from an out-of-network provider from June 28, 2019 to August 26, 2019.
Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. Please see the
chart below.
Date of Service Service Codes Allowed Amount Amount You Owe
6/28/2019 97165 $91.34 $41.10
6/28/2019 97535 $68.68 $30.91
6/28/2019 99203 $108.30 $48.74
6/28/2019 92015 $20.02 $9.01
7/16/2019 97535 $171.70 $77.27
7/24/2019 97535 $296.04 $92.72
8/26/2019 97535 $137.36 $61.81
The total amount you owe is: $361.56.
You have been asked to pay the total coinsurance amount of $361.56 for physician services. Physician services
fall within the physician/practitioner services, including doctor's office visits 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 coinsurance for physician services provided from June 28, 2019 to
August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance transport(A0428) ground mileage (A0425) provided December 21, 2018.
You asked the Plan to pay for the ambulance transport. You say that you are on oxygen and had knee replacement and you had to get to your follow up after surgery appointment. The Plan denied your request. The Plan says this service was billed with a location that is excluded. A physician's office is not a covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance transport(A0428) ground mileage (A0425) provided December 21, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring system and supplies.
You asked the Plan to pre-approve a continuous glucose monitoring system and supplies. You say that the enrollee needs a Dexcom G6 continuous glucose monitoring system to be forewarned about any impending hypoglycemic episodes. The Plan denied your request. The Plan says the enrollee's current glucose monitor is still under reasonable useful lifetime and there is no documentation that it is not meeting the enrollee's needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a FreeStyle Libre continuous glucose monitor, approved in June 2018. The FreeStyle Libre continuous glucose monitor serves the same purpose as the requested continuous glucose monitoring system and supplies. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring system and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Diabetic Testing Supplies (A4253, A4259, A4256, A4253) provided August 13 to November 1, 2019.
You asked the Plan to pay for the diabetic testing supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says rules for telehealth were not met and the proof of delivery provided was not valid.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery submitted for review was not itemized and contained no order or tracking number to validate the items delivered. Therefore, we decided that the Plan does not have to pay for Diabetic Testing Supplies (A4253, A4259, A4256, A4253) provided August 13 to November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-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 1/11/20 due to bradycardia, weakness, and fatigue. 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, documentation supports a treatment plan of oral antibiotics, foley catheter 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.