Persius/hicric huggingface dataset:
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 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 IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane, Carboplatin, Pembrolizumab, Ondansetron, and Dexamethasone.
You asked the Plan to pre-approve Abraxane, Carboplatin, Pembrolizumab, Ondansetron, and Dexamethasone. You say that the medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Abraxane, Carboplatin, Pembrolizumab, Ondansetron, and Dexamethasone. Our reviewer says that the medications are not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drugs are indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 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 Abraxane, Carboplatin, Pembrolizumab, Ondansetron, and Dexamethasone have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane, Carboplatin, Pembrolizumab, Ondansetron, and Dexamethasone.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (EM) services provided in an assisted living facility (ALF) on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the ALF EM services. You say that this should be covered without authorization as this was an urgent/emergent visit. The Plan denied your request. The Plan says this is not considered emergent for the diagnosis of confusion.
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. This cannot be reasonably considered an emergency service if the confusion was low enough in severity to warrant evaluation in the enrollee's home only. 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 the evaluation and management (EM) services provided in an assisted living facility (ALF) on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure (22899, C9752, C9753).
You asked the Plan to pre-approve an intracept procedure. You say that the intracept procedure is medically necessary and the most effective treatment for the enrollee at this time. The Plan denied your request. The Plan says there are not enough studies to show that this procedure is safe and effective.
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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental for low back pain. More research is needed to show safety and efficacy for low back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure (22899, C9752, C9753).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 9, 2021.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission for a left knee arthroplasty.

You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says none of the requirements for a hospital stay are met.

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 pay for 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 record does not show that at the time of inpatient admission, the admitting physician reasonable expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient admission for a left knee arthroplasty is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission for a left knee arthroplasty.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to adjust the copayments for the intravenous infusions, for therapy, prophylaxis,
or diagnosis (96365) provided. We also decided that the Plan does not have to waive the copayments for these
services.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan says that the copayments have been applied correctly to the services provided.
We decided that the Plan has to adjust the copayments for the intravenous infusions, for therapy,
prophylaxis, or diagnosis (96365) provided from April 27, 2021, through May 25, 2021, to $20 per service.
The cost sharing applied in this case by the Plan referenced a $295 copayment applicable for outpatient
surgery. However, the Plan contract states that a $20 copayment applies to outpatient hospital services rendered
by a physician specialist. The services provided in this case were inappropriately processed as outpatient
surgery. Therefore, we decided that the Plan has to adjust the copayments for the intravenous infusions, for
therapy, prophylaxis, or diagnosis (96365) provided from April 27, 2021, through May 25, 2021.
We also decided that the Plan does not have to waive the copayments for the intravenous infusions, for
therapy, prophylaxis, or diagnosis (96365) provided from April 27, 2021, through May 25, 2021.
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 $20
copayment for outpatient hospital services rendered by a physician specialist. Therefore, we decided that the
Plan does not have to waive the copayments for the intravenous infusions, for therapy, prophylaxis, or
diagnosis (96365) provided from April 27, 2021, through May 25, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laser treatment (96921) provided on December 15, 2020.
You asked the Plan to pay for laser treatment. You say that this was medically necessary. The Plan denied your request. The Plan says this was cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. We looked at this the file and Medicare rules. The submitted records indicate that this was a cosmetic procedure to treat the enrollee's hair loss. Based on this information, we decided that Medicare rules for coverage of laser treatment have not been met. Therefore, we decided that the Plan does not have to pay for laser treatment (96921) provided on December 15, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the travel and lodging expenses related to post-transplant care incurred from March 24, 2021, through March 27, 2021.
You asked the Plan to provide reimbursement for the travel and lodging expenses. You say that Medicare pays for post heart transplant travel. Since it is medically necessary for you to go to a different city to check for heart rejection, pulmonary issues, and immune deficiency issues, the Plan must reimburse you for this just as Medicare would. The Plan denied your request. The Plan says this is not a covered benefit under your Plan. You were not provided with this transplant as a member for the Plan. These expenses are only paid within one year of the transplant.
The Plan must follow Medicare rules. Medicare rules say that when the Plan provides transplant services at a distant location, farther away than the normal community patterns of care for transplant services, they must provide reasonable travel and lodging. In this case, you were not required to receive this transplant at a distant location by the Plan. You were not a member of the Plan when the transplant occurred on July 3, 2019. Travel and lodging expenses related to returning to the transplant center in this case are not required to be covered by the Plan. Therefore, we decided that the Plan does not have to provide reimbursement for the travel and lodging expenses related to post-transplant care incurred from March 24, 2021, through March 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroencephalogram (95882), Needle electromyography (95870) and unlisted neurological service (95999) provided on March 9, 2021.
You asked the Plan to pay for the Electroencephalogram, needle electromyography and unlisted neurological procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95822 is Electroencephalogram (EEG); recording in coma or sleep only.
The CPT Code Manual definition of code 95870 is Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than paraspinal, cranial nerve supplied muscles, or sphincters. The CPT Code Manual definition of code 95999 is Unlisted neurological or neuromuscular diagnostic procedure. 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 Electroencephalogram, needle electromyography and unlisted neurological procedure. Our reviewer says that CPT codes 95822, 95870, 95999 do not meet criteria for billing or reimbursement consideration. Our reviewer found no documentation of neurological testing was found to support the Current Procedural Terminology (CPT) codes billed. 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 Electroencephalogram, needle electromyography and unlisted neurological procedure. have not been met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (95882), Needle electromyography (95870) and unlisted neurological service (95999) provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2020.

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 the services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing setting and
should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on August 25, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that repeat imaging is not supported without the results of prior imaging that show a clear reason for it.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found with an elevated calcium of 125 ascites and pelvic mass ovarian origin is likely. MRI is a very sensitive tool with which to evaluate the nature of a pelvic mass and such evaluation is not available on computed tomography (CT) or ultrasound given the degree of ascites and size of the pelvic mass. MRI makes sense for pre surgical evaluation and 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis for the enrollee.

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: 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 you need rehabilitation for your leg. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support a need for a skilled physical therapist to make more home visits at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the documentation doesn't support that the enrollee requires additional skilled services. There are no additional rehabilitation services required to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health occupational therapy visits.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says your current formal therapy should meet clinical expectations with the eighteen total approved visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 additional visits. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no documented skilled occupational therapy needs. You are functioning at a level commensurate with a lower level of care. As such, the requested ongoing home health services are not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health occupational therapy visits.