Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 15, 2019 to October 8, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that this admission was medically necessary to treat the enrollee. The Plan denied your request. The Plan says that the enrollee's condition was not such that inpatient admission was necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the ED 9/15/19 after a mechanical fall at home complaining of right hip pain. Evaluation including physical exam and x-rays of the knees, bilateral tib/fib, lumbar spine, CT of the head and CT right hip were negative for fracture or any acute process. She was evaluated by physical medicine and admitted. She received physical/occupational therapy and was evaluated by Psychiatry. She was discharged when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 15, 2019 to October 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care beyond March 26, 2020.You asked the Plan to pre-approvethe continued SNF care. You say that you feel that you need to remain in the SNF at this time.The Plan denied your request. The Plan says you have reached a functional plateau and daily skilled therapy is not required to maintain your current functional level.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 the continued SNF care. Our reviewer says that daily skilled services are notnecessary. Our physician reviewer found this patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 3/26/20. The patient does not have a new tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need beyond 3/26/20. The patient does not require skilled therapy services with the specialized skill,knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 3/26/20. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF beyond 3/26/20.As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond 3/26/20.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 continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care beyond March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 24, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 referring provider 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 forthe medical services provided on October 24, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these 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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. 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 the medical services provided to the enrollee by an out-of-network provider
on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe low dose CT scan provided on October 21, 2019.You asked the Plan to pay forthe LDCT scan. The Plan denied your request. The Plan says this is only covered once per year.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 $0 copayment for an LDCT scan once every 12 months. Review of the file shows that an LDCT scan was provided to the enrollee on October 21, 2019. The records also show that the plan paid for an LDCT scan provided on January 7, 2019. As this service is only covered once every 12 months, the requested imaging exceeds the benefit limit, and is not covered.Therefore, we decided that the Plan does not have to pay forthe low dose CT scan provided on October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasonic guidance provided on November 26, 2019.You asked the Plan to waive the copayment forthe ultrasonic guidance. You say that this was part of the surgery. You say that this should not have been billed.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay a $60 copayment for in-network, Medicare-covered x-rays and ultrasounds. You have been asked to pay a $60 copayment for the ultrasonic guidance. The ultrasonic guidance falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe ultrasonic guidance provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 10, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you do not need prior authorization for an office
visit. The Plan denied your request. The Plan says prior authorization is required for services that are provided
by an out-of-network provider.
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 provided on October 10, 2019 by an
out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 6, 2019 to September 14, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says the appropriate G and Q codes were missing on the claim for the billed dates of service.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the G and Q codes which are required for processing. Additionally, S codes are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 6, 2019 to September 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve leucovorin, palonosetron HCl, fluorouracil, and irinotecan liposome 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 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 not medically necessary. Our physician reviewer found the enrollee has metastatic adenocarcinoma of the esophagus that is HER 2 negative. The National Comprehensive Cancer Network (NCCN) guidelines recommend that two drug combinations are preferred. None of the recommended regimens include the requested regimen. The requested combination of leucovorin, palonosetron HCl, fluorouracil, and irinotecan liposome is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve leucovorin, palonosetron HCl, fluorouracil, and irinotecan liposome for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, LED light kit, USB charger, arm rest pouch and a power seat elevation feature for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary for the enrollee. The Plan denied your request. The Plan says that although there are three approved power options on this wheelchair, there is not a medical need to control these power options through the joystick.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 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 expandable controller, expandable controller harness and electronic connection are not considered medically reasonable and necessary in this case. The medical records indicate that the enrollee has 4/5 strength, which is adequate to operate the approved power chair which has built in options to facilitate the needed actions. The enrollee is independent with feeding, bowel and bladder management, bathing, dressing, meal prep with mobility assistance. The enrollee is independent with operating the power wheelchair with a standard joystick. The notes do not show a medical necessity to control the power options through the joystick. The upper limb strength and function are therefore adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options in the approved chair. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage for an expandable controller, expandable controller harness and electronic connection. 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 expandable controller, expandable controller harness and electronic connection have not been met. The LED light kit, USB charger and arm rest pouch 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. A power seat elevation feature is non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, LED light kit, USB charger, arm rest pouch and a power seat elevation feature for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 25, 2019 through December 2, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because Per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status code of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 25, 2019 through December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no complex medical problem that requires care in inpatient rehab.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. Her anemia is improved and stable. Her pain is not uncontrolled. There is no indication that her medical management needs an IRD. The enrollee may benefit from PT and OT but the documentation does not indicate that the enrollee requires this on an intensive level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.
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 inpatient rehabilitation facility care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you do not require the intensity of services provided at an inpatient rehabilitation facility. Specifically, you do not require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveNeulasta (pegfilgrastim).You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysit is unknown if there has been a trial and failure of Fulphila or Udenyca before this request.Medicare covers PartB 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Neulasta has been requested for the prevention of chemotherapy induced febrile neutropenia. Records sent for review do not show that you have tried and failed the step therapy drugs Fulphila and Udenyca before using Neulasta. Records also do not show that the step therapy drugs would not be as effective for you as the requested drug, and/or is contraindicated.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveNeulasta (pegfilgrastim).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an acute inpatient rehabilitation facility admission.
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 that the enrollee does not require the intensity of services provided at an inpatient rehabilitation facility. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an 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 RiMatrix skin substitute.
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 the services are considered experimental/investigational in nature.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a pressure wound on your back for more than 12 months. The requested RiMatrix skin substitute is not more effective for wound healing over standard treatments for chronic wounds. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve RiMatrix skin substitute.