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 the LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs are met in the current setting.
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 the record indicates that following a cardiac arrest, the enrollee is unable to be weaned. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental service. You say that you have an infection. You say that you are in pain. You also say that you need to see an oral surgeon for this extraction. The Plan denied your request. The Plan says dental services must be provided by a participating general dentist. The Plan also says dental services performed by an oral surgeon are not covered.
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 extraction is not among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve should prosthesis to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve should prosthesis. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve should prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that although surgical decompression is the other treatment option, the enrollee does not want to have such a such a significant surgical procedure at this time when an FDA approved minimally invasive treatment option is available. The Plan denied your request. The Plan says experimental and investigation procedures are not covered by Medicare.
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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is 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 the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (22869).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Pegfilgrastim.
You asked the Plan to pre-approve Pegfilgrastim. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is 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 Pegfilgrastim. Our reviewer says that the documentation does support that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has limited stage non-small cell lung cancer. Pegfilgastrim is Food and Drug Administration approved to decrease the incidence of infection (as manifested by febrile neutropenia), in enrollees with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. This enrollee had neutropenic fever, is elderly, and is receiving chemotherapy. The enrollee's risk of neutropenic fever is greater than 20% which is clinically significant. Therefore, the enrollee meets criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pegfilgrastim have been met. Therefore, we decided that the Plan has to pre-approve Pegfilgrastim.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the referring physician. You say that these services were time sensitive. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-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 had network providers available who could have provided 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 lab work provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on May 7, 2021, by the out of network dentist.
You asked the Plan to pay for the dental service. You say that you were advised by the office staff that the dentist was in network with your plan. The Plan denied your request. The Plan says if you see an out of network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. The Plan also says out of network dentists may bill you for any amount greater than the payment made by the plan to the provider.
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 and extractions are listed as covered, dental services performed out of network may have a higher cost share amount. There is a 55% coinsurance for extractions that are performed out of network. Additionally, out of network dentists may bill you for any amount greater than the payment made by the plan to the provider. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) provided on May 7, 2021, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture.
You asked the Plan to pre-approve the upper partial denture. You say that you cannot wait the five years and are appealing the authorization. The Plan denied your request. The Plan says dentures are limited to one set every 5 years.
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, you also have a maximum benefit of one set of dentures every five years. The Plan paid for an upper partial denture provided on August 23, 2017, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional routine transportation trips (A0120).
You asked the Plan to pre-approve the additional routine transportation trips. You say that the additional
transportation trips are medically necessary. The Plan denied your request. The Plan says the benefit has been
exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve 60 additional routine transportation trips (A0120).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve psychotherapy services. You say that out-of-network providers have been covered in the past and you were told you could self-refer. The Plan denied your request. The Plan says these services are 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-of-network (OON) provider.
Your complaint about being told the incorrect process to see an out-of-network provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine.
You asked the Plan to pre-approve Promethazine. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Promethazine have not been met. Therefore, we decided that the Plan does not have to pre-approve Promethazine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 13, 2021, to May 15, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had only been released 4 hours from inpatient care before returning to the emergency room. The Plan denied your request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $395 copayment per day for days 1-5 for inpatient hospital care. Records show that you were in the hospital from May 10, 2021, to May 12, 2021. You returned to the emergency room on May 12, 2021 after your discharge. You were then admitted a second time from May 13,
2021, to May 15, 2021. You have been asked to pay a $395 copayment per day for days 1-5 for the inpatient hospital services. You were charged this copayment on May 10, May 11, May 13, and May 14. You were not charged a per-day copayment for May 12 or May 15. 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 inpatient hospital services you received from May 13, 2021, to May 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the doctor is looking for the stability of the lung nodule that was last scanned on 08/20/2018. The enrollee is concerned about the length of time since last scanned. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested service
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above-described criteria. We reviewed the file and the Medicare rules. We find that the records show that the enrollee does not have a 30
pack year history of tobacco smoking and has quit smoking over 15 years ago. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on
March 18, 2021.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not support a high level of medical decision making. The documentation supports moderate medical decision making. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).
You asked the Plan to pre-approve a portable oxygen concentrator (E1392). You say that you need a POC to be more active. The Plan denied your request. The Plan says you should arrange a referral for an evaluation to determine if a home-fill compressor with smaller tanks is appropriate to meet your in-home needs.
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 looked at the file, and Medicare rules. You have not tried a standard portable oxygen system and there is not enough clinical information to determine medical necessity. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator (E1392) have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for non-invasive extremity arterial studies (including digits) (93923) provided April 28, 2021.
You asked the Plan to pay for the diagnostic service. You say that the procedure was performed at the request of the referring doctor, as the enrollee's medical condition proved the medical necessity for the service. The Plan denied your request. The Plan says the diagnosis billed was not appropriate for the procedure.
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 93923 is noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study.
We find that CPT code 93923 is not supported in the medical record. Specifically, there are certain diagnosis codes that support the medical necessity of the service performed. The the diagnoses billed is not listed as appropriate diagnoses codes. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for non-invasive extremity arterial studies (including digits) (93923) provided April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit, and the electrocardiogram provided
on February 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the annual wellness visit and the electrocardiogram. You say that the services are
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 have network providers
available who could have provided 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. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the annual wellness visit, and the electrocardiogram provided on
February 11, 2021 by an out-of-network (OON) provider.