Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for dental services.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are 100 in-network providers within a 50 mile radius of your zip code.  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. The Plan covers dental services when they are provided by participating dentists.       We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for dental services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monoferric (J1437).  You asked the Plan to pre-approve Monoferric. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Monoferric. Our reviewer says that the requirements for coverage of Monoferric have not been met. Our physician reviewer found he Plan requires a trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not have to pre-approve Monoferric (J1437).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that you need intense rehabilitation, cardiac monitoring and monitoring of progression of your stroke. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.  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 that 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 stroke with aphasia. Your medical problems 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. While you have a need for physical, speech and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy (90832) provided on June 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for psychotherapy. You say that the treatment received by the member was medically necessary. The Plan denied your request. The Plan says both the rendering provider is a non-participating provider. The Plan also says that the referring provider involved in these services is a non-participating provider with the plan and the Plan did not authorize any services for this provider or for the facility.  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 provider at issue in this case is not a network provider with the Plan. 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 psychotherapy. Our reviewer says that this does not meet criteria. Our physician reviewer found based on the review of the records provided, this patient does not require treatment by an out-of-network provider as the medical plan is able to provide a psychotherapist for the treatment of this patient's condition. Our doctor also found that this patient's condition is not considered urgent/emergent.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy have not been met.   The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for psychotherapy. Therefore, we decided that the Plan does not have to pay for psychotherapy (90832) provided on June 18, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce any of the cost share charged for the outpatient surgery and
related services provided December 17, 2020.
You asked the Plan to reduce the cost share for this outpatient surgery and related supplies. You say that you do
not believe this cost share is correct.
The Plan denied your request. The Plan says these were outpatient services and each cost share was charged
based on the services provided and the Plan contract agreement. We partially overturned the Plans
denial. The Plan requested a reopen and stated that we did not interpret the contract correctly.
The Plan explained that you underwent an outpatient total knee replacement. Unlike inpatient procedures where
there is one copayment inclusive of all services, outpatient services can incur a cost share for each service, drug
and or item. You were assessed copayments for the implanted knee device, Part B drugs, imaging, physical
therapy, self-administered drugs and related prosthetic and treatment supplies.
Based on the information provided in the reopen, the Plan is correct 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 cost share for each outpatient
service provided. Self-administered drug costs must be submitted to your Medicare Part D carrier.
You have been asked to pay the correct amount for each service and item based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Reimbursement
for Part D self-administered drugs during this outpatient stay must be submitted to your Medicare Part D
carrier. Therefore, we decided that the Plan does not have to reduce any of the cost share for services provided
for outpatient surgery provided on December 17, 2020.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pre-approve the home health services provided from March 27, 2021, through April 13, 2021.  You asked the Plan to pre-approve the home health services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that the claim has not been billed with an appropriate revenue code.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied payment because an appropriate revenue code was not billed with code Q5001. Upon review, there is no evidence provided about why the revenue codes that were submitted were incorrect. It is the burden of the Plan to substantiate their denial with information, specifically in this case regarding what revenue codes were incorrect. In addition, the rule the Plan cites specifically is for reporting one of the three Q codes for home health claims which the provider did. There is no information in these rules submitted about revenue codes.  Therefore, we decided that the Plan has to pre-approve the home health services provided from March 27, 2021, through April 13, 2021.   If the Plan does 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/or send 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power elevating seat.

You asked the Plan to pre-approve power elevating seat. You say that you would like this item to access items in cabinets and on shelves. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power elevating seat have not been met. Therefore, we decided that the Plan does not have to pre-approve power elevating seat.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on May 31, 2021.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 12014 is not separately payable.  

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 12014 (simple repair of superficial wounds) and 21320 (closed treatment of nasal bone fracture with stabilization). Code 12014 is a column II code with a modifier indicator of 1 when billed with column I code 21320. 

Code 12014 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on May 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  

You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.  

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for rhabdomyolysis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that laboratory results and test results were not available.  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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found liver function test (LFT) results were provided and appear to have been drawn on 12/2/21. The LFT levels were normal. The enrollee has a prior elevation of lipase, so the concern would be underlying pancreatitis. As the request has been denied due to absent LFT results, the denial reason is invalid as the normal test results were normal. Thus, due to the duration of symptoms, the painful abdomen on physical exam and the palpated abdominal firmness CT of the abdomen and pelvis should be approved.  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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis.   If the Plan does 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/or send 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Trulicity 1.5mg/0.5ml.  You asked the Plan to pre-approve Trulicity. You say that Trulicity is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for Part B coverage.    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 Trulicity 1.5mg/0.5ml.   Benefits for Trulicity 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care admission and services.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital admission is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital admission does not meet criteria.  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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is undergoing a planned L2-5 laminectomy. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gemtesa.  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 self-administered drugs are not covered.  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 Gemtesa.   Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953).  You asked the Plan to pre-approve bone replacement grafts. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by the Plan's dental benefit.  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 bone replacement grafts for ridge preservation (D7953).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 12, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. We overturned the Plans denial. The Plan
requested a reopen and stated that we did not apply the correct criteria. The Plan states this claim denied
because the provider billed this service inappropriately. Based on the medical records, the provider coded the
claim incorrectly. The records provided with the reopen do not include definitive laboratory results for 22 or
more drug classes to support the coding criteria for the code billed on date of service. There was a total of 18
drug classes counted from the laboratory results received.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim
cannot be paid as billed as the records provided do not support the services billed. The records show 18 drug
classes were reported and not 22. Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for drug testing provided to the enrollee on May 12, 2021.