Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care attendant services.
You asked the Plan to pre-approve personal care attendant. You say that the enrollee's safety is at risk without
an aid. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because this custodial care is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of personal care attendant have not been met. Specifically, we find that the services at issue in this
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve
personal care attendant services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from July 16, 2020, to July 26, 2020, and billed with DRG (diagnosis related group) 471.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says diagnosis E43 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 471, cervical spinal fusion with major complications or comorbidities, and a secondary diagnosis of E43, unspecified severe protein-calorie malnutrition. 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 inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found it was reported that the patient was eating about 50% of his meals but without dysphagia or other issue. Oral supplemental needs were noted and given. There was no indication parenteral nutrition was needed or that the patient had weight loss or low albumin to indicate severe protein-calorie malnutrition, meaning diagnosis E43 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from July 16, 2020, to July 26, 2020, and billed with DRG (diagnosis related group) 471.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Boost nutritional supplement.
You asked the Plan to pre-approve the supplement. 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. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Boost nutritional supplement.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa tablet 75mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not have a plan with its own pharmacy (drug) benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 tablet 75mg for
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
You asked the Plan to pre-approve the CGM supplies. You say that the enrollee has been able to maintain good glycemic control using this CGM and needs 12 units of insulin per day. The Plan denied your request. The Plan says the enrollee does not use multiple insulin injections and these injections are not frequently adjusted.
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 administrations and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic colonography (CTC) for the enrollee.

You asked the Plan to pre-approve the scan. You say that the enrollee has abnormal bowel habits and a family history of colon cancer. The Plan denied your request. The Plan says the requested scan is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography (CTC) is not a covered benefit. 

The requested scan is not considered reasonable or necessary by Medicare. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic colonography (CTC) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wrist wound debridement procedure
you had at an ambulatory surgery center on August 31, 2021.
You asked the Plan to waive the copayment for the wrist wound debridement procedure. You say that your
doctor advised that he couldn't do this procedure in his office because it wasn't sterile. That is why you had to
go to the ambulatory surgery center. You stated that you are not able to afford this copayment. 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 $350
copayment for outpatient surgery and services at an ambulatory surgical center.
You have been asked to pay a $350 copayment for the wrist wound debridement procedure. This copayment
applies regardless of the reason for going to the ambulatory surgery center. 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 wrist wound debridement procedure you had at an ambulatory surgery center on
August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick female catheter.
You asked the Plan to pre-approve a PureWick female catheter. You say that the requested item is a necessity
for your care. The Plan denied your request. The Plan says the requested item is duplication of care.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have been approved for a female catheter system. The approved system serves the same
purpose as a PureWick female catheter. Therefore, we decided that the Plan does not have to pre-approve a
PureWick female catheter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the full course of treatment in the hospital has not been completed.
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 indicating medical necessity for LTACH services. 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 she 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MICRA leadless pacemaker.

You asked the Plan to pre-approve the pacemaker. You say that this is medically necessary. The Plan denied your request. The Plan says these devices are not covered when furnished outside of an approved study.

The Plan must follow Medicare rules. Medicare rules say that a leadless pacemakers is only covered at this time when provided as part of an approved clinical study. 

This pacemaker is not being requested as part of an FDA or Medicare-approved clinical study. Based on this information, we decided that Medicare rules for coverage of the pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve the MICRA leadless pacemaker.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 11, 2021.

You asked the Plan to pay for lab tests. You say that you are dependent on receiving patient information from the ordering provider. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an assisted living facility setting, therefore the POS code 11 - indicating an office setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are 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. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation services was not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are 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. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee arthroscopy with meniscectomy (29881) provided on June 21, 2021.

You asked the Plan to pay for a knee arthroscopy with meniscectomy. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the procedure at issue is experimental/investigational.

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 a knee arthroscopy with meniscectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.

Our physician reviewer found that detailed documentation is not evident in the case record regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There is no evidence of trial and failure of formal physical therapy prior to the surgical procedures. Trial and failure of all reasonable less invasive/conservative measures is typically indicated prior to surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 

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 knee arthroscopy with meniscectomy have not been met. Therefore, we decided that the Plan does not have to pay for a knee arthroscopy with meniscectomy (29881) provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network dental services.
You asked the Plan to pre-approve out-of-network dental services. The Plan denied your request. The Plan says out-of-network dental services are not covered, and in-network providers are available.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve out-of-network dental services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine Modivcare mileage.
You asked the Plan to pre-approve additional mileage. You say that this matter is medically necessary, and you
need to see your doctor urgently. The Plan denied your request. The Plan says the service is a covered benefit,
but you exceed limits set in your Plan agreement.
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 24 one-way routine transportation trips, and each one-way trip must not exceed 50 miles
of driving distance.
We looked at your request, the records in the case file, and the rules. We have confirmed with Google Maps
that the shortest route to your providers office is 74.2 miles which exceeds your benefit mileage limit. Based on
this information, we decided that the Plan's rules for coverage of routine transportation have not been met.
Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to preapprove
additional routine Modivcare mileage.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 4, 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 Healthcare Common Procedure Coding System (HCPCS) code G0480 (1 Unit) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

In this case, the CPT Code Manual definition of code G0480 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; 1-7 drug class(es), including metabolite(s) if performed." 

We find that CPT code G0480 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 February 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not tried and failed the preferred step therapy alternatives.
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 the injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan,
requires that these be trialed first. The documentation does not outline contraindications or reasons these
medications were not considered or that the plan's required drugs would likely be less effective and/or likely
have adverse effects for the enrollee. Without the support of the documentation, Gel-One is not approved as
step criteria have not been met.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Gel-One injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital room and services provided from August 1, 2021, to August 4, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that you feel you should not be billed for anything, because you did not see a doctor while you were hospitalized. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $325 copayment for each of the first six days of an inpatient stay.
You have been asked to pay a $975 copayment for the three-day inpatient hospital stay ($325 x 3 = $975). 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 inpatient hospital room and services provided from August 1, 2021, to August 4, 2021.