Persius/hicric huggingface dataset:
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 admission to an LTACH is medically necessary for management of the enrollee's multiple comorbidities. The Plan denied your request. The Plan says admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on February 15, 2021.

You asked the Plan to waive the copayment for outpatient surgery. You say that you take issue with this increased copayment as the Plan gave no indication that this would be included. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $300 copayment for in-network outpatient surgery at an outpatient hospital facility.

You have been asked to pay $300 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 epidural injection provided on February 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you meet the criteria for IRF care. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for anemia, gastrointestinal bleeding, a fall and rhabdomyolysis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions, 1 to 3 teeth per quadrant, (D7311 x 3).
You asked the Plan to pre-approve the dental services. You say that you need these services. You say that without these services, you cannot get your dentures. You also say that you need the dentures so that you can eat. The Plan denied your request. The Plan says alveoloplasty in conjunction with extractions 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions, 1 to 3 teeth per quadrant, (D7311 x 3).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0157, G0495, Q5001) provided December 10, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 G0157, G0495, & Q5001 is not supported in the medical record. Specifically, the claim did not include a valid Type of Bill. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.
Therefore, we decided that the Plan does not have to pay for home health services (G0157, G0495, Q5001) provided December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator.
You asked the Plan to pre-approve an auricular nerve stimulator. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 an auricular nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is experimental therapy and therefore, the request is deemed 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 an auricular nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 20, 2020.
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 are not payable as billed.
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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 for the drug testing coded G0483 provided on November 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's care can be provided at an alternative level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 physician reviewer found that the enrollee does not require the services of a skilled professional nurse to safely provide medically necessary treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. His functional level does not require services of a qualified therapist to safely provide medically necessary treatment in a SNF. He does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. 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 a skilled nursing facility (SNF) admission and services.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke in December of 2020 and are currently living in an assisted living facility. Your medical conditions are stable. There are no complex
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for a myocardial perfusion imaging (78452) and a regadenoson injection (J2785) provided on February 25, 2021.
You asked the Plan to waive the cost-share for diagnostic imaging and an injection. You say that you should not have to pay two cost shares. The Plan denied your request. The Plan says the cost shares you are being charged is correct.
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 $110 copayment for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $110 copayment for a diagnostic imaging. The EOC confirms that $110 is the required copayment for this service. You have also been asked to pay a 20% coinsurance for an injection. The EOC confirms that 20% is the required coinsurance for a Medicare Part B drug. The allowed amount of the claim is $237.52, resulting in a coinsurance obligation of $47.50. Your total cost-share is $157.50 ($110 + $47.50 = $157.50). A diagnostic imaging and an injection fall within the outpatient diagnostic tests and therapeutic services and supplies and Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for a myocardial perfusion imaging (78452) and a regadenoson injection (J2785) provided on February 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen (74170) provided March 17, 2021.
You asked the Plan to waive the copayment for the CT scan of the abdomen. You say that you would like this copayment waived as it was previously approved. The Plan denied your request. The Plan says this claim did not deny; the copayment has processed correctly in this case.
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 $200 copayment for CT scans performed by a provider other than your primary care physician.
You have been asked to pay a total cost share of $166.55 for the CT scan of the abdomen which is less than the required $200 copayment. This service falls within the CT scans performed by a provider other than your primary care physician 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 the computed tomography (CT) scan of the abdomen (74170) provided March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).
You asked the Plan to pre-approve a powered upper extremity range of motion assist device. You say that this requested device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this device is not covered.
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 a powered upper extremity range of motion assist device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The requested device is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The device is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that this device will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 powered upper extremity range of motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93308) provided March 3, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you received a bill in the amount of $110. You went for an echogram at the office, and you feel that you are being billed incorrectly. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage
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 $110 copayment for Medicare covered diagnostic radiology services.
You have been asked to pay $110 copayment for the diagnostic service. The diagnostic service 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 for echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93308) provided March 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Ketamine IV Fusion.
You asked the Plan to pre-approve a Ketamine IV Fusion. You say that the enrollee has had no improvement despite a plethora of conventional headache management tools and treatments. You say that, given the enrollee's refractory headaches, consistently high pain levels, and previous improvement, inpatient ketamine is recommended. The Plan denied your request. The Plan says medical studies have not proven that the requested treatment is helpful for the enrollee's health problem.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ketamine IV Fusion. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no evidence to date from well-designed clinical studies to support the use of IV Ketamine in any headache disorders. The evidence on the use of IV Ketamine for headache disorders is limited to case series. There have only been two small randomized controlled trials (RCTs) which otherwise produced conflicting results and had methodological limitations. There otherwise remains a need for prospective studies of the requested procedure/service for the acute treatment of headaches (and the prophylactic therapy in headaches). The use of Ketamine would not otherwise be said to be supported by current literature and further study is necessary. The drug is not otherwise supported for use in this condition within its FDA approved labeling or the Compendia. 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 Ketamine IV Fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a Ketamine IV Fusion.