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

 We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission.  You asked the Plan to pre-approve the continued inpatient psychiatric admission. You say that the enrollee still exhibits significant impairment and discharging them to the community would put the enrollee, and potentially others, at risk. The Plan denied your request. The Plan says this request is not medically necessary because the records received show that the enrollee's condition has improved, and they are no longer a threat to themself or others.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued inpatient psychiatric admission. Our reviewer says that this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 4, 2021, forward. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Our reviewer found that it does not appear that active treatment was taking place and the services were not reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. The record does not include an individualized treatment plan however the entire record is not present. Our physician reviewer also found that it appears that the services were supervised and evaluated by a physician.  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 inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity.  You asked the Plan to pre-approve Evenity. You say that you would like this drug to be reconsidered for coverage. The Plan denied your request. The Plan says the conditions needed to approve this drug 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 Evenity. Our reviewer says that Evenity is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drugs Tymlos, Forteo, or Prolia before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 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 Evenity. have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says SNF admission is not medically necessary.  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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic injection of the paravertebral facet (zygapophyseal) joint (64493, 64494, 64495) provided on August 4, 2021, by an OON provider.  You asked the Plan to pay for diagnostic injection of the paravertebral facet (zygapophyseal) joint. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance. 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 diagnostic injection of the paravertebral facet (zygapophyseal) joint (64493, 64494, 64495) provided on August 4, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99213) provided on May 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider, and the member does not have out of network coverage for services determined to be non-urgent/emergent.  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 a specialist office visit (99213) provided on May 17, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on August 11, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that the Plan should cover these charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each emergency department visit.      You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the Emergency Care 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 emergency room (ER) visit provided on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 23, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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, we have confirmed that code 71250 is a column II code to column I code 71260. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on April 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient hospital level of care for total shoulder replacement surgery.  You asked the Plan to pre-approve inpatient hospital level of care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is approved as an ambulatory procedure and there is no documentation to support an expectation that the enrollee will require a greater than 2 midnight hospital stay.  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 inpatient hospital level of care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient level of care for the requested shoulder surgery. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The documentation does not support an expectation that 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 inpatient hospital level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital level of care for total shoulder replacement surgery.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 13, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the diagnosis code does not substantiate the service.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that Medicare criteria for coverage of the Comprehensive Urine Wellness Panel performed on 01/13/2021 have been met in this case. The diagnoses indicated in the provided medical records do not support necessity of the Comprehensive Urine Wellness Panel performed on 01/13/2021.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Shingrix vaccine (90750) and administration (90471) provided on April 2, 2021.  You asked the Plan to pay for the vaccine and administration. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says this vaccine is not covered under the enrollee's medical benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine and administration. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the vaccine and administration. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine (90750) and administration (90471) provided on April 2, 2021.   Benefits for the vaccine and administration 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 inpatient rehabilitation services are medically necessary for the enrollee to regain maximum function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can be provided in a lower level of care.  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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Transmitter; external, for use with interstitial continuous glucose monitoring (CGM) system (A9277), provided on July 22, 2021.  You asked the Plan to pay for a CGM transmitter. You say that the item is medically necessary. The Plan denied your request. The Plan says you did not use one of the Plan's preferred brands.  The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM transmitter have not been met. Specifically, your Plan does cover certain non-therapeutic CGM equipment and supplies, however, you did not use one of the preferred brands and no medical records were submitted to determine the purchased brand was medically necessary over the preferred brand. Therefore, we decided that the Plan does not have to pay for a Transmitter; external, for use with interstitial continuous glucose monitoring (CGM) system (A9277), provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met.  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 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Arformoterol Tartrate (J7605).  You asked the Plan to pre-approve Arformoterol Tartrate. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria.    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 Arformoterol Tartrate. Our reviewer says that Arformoterol Tartrate (J7605) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Perforomist (Formoterol). Our reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ARFORMOTEROL TARTRATE have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformoterol Tartrate (J7605).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (procedure code 71045) provided to the enrollee on August 30, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied because it was bundled to another service billed on the same day by the same provider.  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 71045 is "Radiologic examination, chest; single view."  We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records indicate that procedure code 32557 LT (pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance) was performed on August 30, 2021. CPT 71045-26 has a bundled relationship to CPT 32557-LT; however, an acceptable modifier is allowed to unbundle the relationship providing the medical records justify the use of an appropriate modifier. In this case, the medical records do not include sufficient documentation to justify the use of a modifier to unbundle 71045 26 from 32557-LT, therefore 71045-26 is not eligible for separate reimbursement.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (procedure code 71045) provided to the enrollee on August 30, 2021.