Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0427, A0425) provided on May 31, 2021.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you cannot afford the copayment. The Plan denied your request. The Plan says the copayment was applied 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 $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for emergency ambulance transportation. The service at issue falls within the ambulance services 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 emergency ambulance transportation (A0427, A0425) provided on May 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on July 10, 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 an appropriate modifier was not 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, we have confirmed that code 70450 is a column II code to column I code 70496. 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 (procedure code 70450) provided to the enrollee on July 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the otolaryngology services provided on September 16,
2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that you were told to check your ears. The Plan
denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that
the Plan does not have to pay for the otolaryngology services provided on September 16, 2021, by an out-ofnetwork
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary for the enrollee. This patient has severe COPD with a previous hospitalization for acute-on-chronic hypercarbic and hypoxic respiratory failure. The patient improved on BiPAP in the hospital. There is no demonstrated failure of BiPAP at home. Certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support, and Medicare does not cover a ventilator when used as BiPAP. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.  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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.   Benefits for Eliquis 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve IMRT. You say that you want the Plan to cover the service at issue. The Plan denied your request. The Plan says this service is not covered when rendered by an out-of-network provider.  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 intensity-modulated radiation therapy (IMRT) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nexlizet tablets.  You asked the Plan to pre-approve Nexlizet. You say that you need this drug due to your particular condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexlizet tablets.   Benefits for Nexlizet 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Reblozyl (J0896).  You asked the Plan to pre-approve Reblozyl. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Reblozyl. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 74 yo low grade myelodysplastic syndrome. In this case, the requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis.      The FDA has approved this drug for the treatment of anemia failing an erythropoiesis-stimulating agent and requiring 2 or more red blood cell units over 8 weeks in adults with very low-to-intermediate-risk myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). This patient has no ringed sideroblastas. In addition, the use of Reblozyl for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved clinical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl (J0896).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a total knee arthroplasty (27447).  You asked the Plan to pre-approve acute inpatient hospital care. You say that you will not be able to go home after surgery. You can barely walk or stand, and you are in a lot of pain. The Plan denied your request. The Plan says the procedure is approved, but the associated inpatient care is not medically necessary in this case. The procedure is approved as an ambulatory procedure, and there is no documentation to support the expectation that you will require a greater than two-midnight stay following this surgery.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure listed under code 27447 is not listed on the Centers for Medicare and Medicaid Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation that you will require a greater than 2 midnight stay. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expects that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a total knee arthroplasty (27447).
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve inpatient psychiatric care from December 30, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric hospital services from December 30, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically necessary.  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 inpatient psychiatric hospital services from December 30, 2021, forward. Our reviewer says that the enrollee meets the criteria for acute inpatient mental health treatment beyond the date in question of December 30, 2021, forward. Our physician reviewer found the enrollee was continuing to show disorganized thoughts, grandiosity and paranoid delusions while being internally preoccupied. It did appear that active treatment was taking place beyond the date in question. It did appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee condition or for the purpose of diagnosis.  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 psychiatric hospital services from December 30, 2021, forward have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from December 30, 2021, forward.   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 inpatient mental health treatment.  You asked the Plan to pre-approve inpatient mental health treatment. 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 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 inpatient mental health treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of December 13, 2021, forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety.  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 mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require daily skilled services.  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 your condition does not meet Medicare criteria for continued SNF services.  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 continued skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing services.  You asked the Plan to pre-approve the skilled nursing services. The Plan denied your request. The Plan says you do not meet the guidelines for the requested service which does not appear medically necessary. The Plan also says that your needs can be met with a less complex level of care.  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 skilled nursing services. Our reviewer says that the requested, ongoing, home health skilled nursing services are not shown to be medically necessary or reasonable. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer also found that your homebound status and availability of caregivers are unclear.  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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on January 16, 2021, through January 21, 2021 and billed with diagnosis code J96.01.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the documentation supports the diagnosis code billed. The Plan denied your request. The Plan says the documentation submitted does not support diagnosis code J96.01.  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 diagnosis code J96.01. 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 inpatient hospital services. Our reviewer says that the review has determined that the documentation does not support the secondary diagnosis code J96.01. Our physician reviewer found the emergency department (ED) provider specified the patient arrived to the ED with no acute complaints, stating he is without pain and with no shortness of breath, further noting that the patient is comfortable, resting in bed and is alert and responsive to this examiner. An evaluation of arterial blood gases could not be located within the documentation received. Review of the Vital Signs indicates the patient was weaned to room air on the day of admission January 16, 2021 and maintained oxygen saturations 92-98% on room air throughout the remainder of this encounter. Ttreatment consistent with acute respiratory failure was not found.   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 hospital services provided on January 16, 2021, through January 21, 2021 and billed with diagnosis code J96.01.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Motegrity for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Motegrity for the enrollee.   Benefits for this drug 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: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the application of a skin substitute graft (15275) provided on July 8, 2021.  You asked the Plan to pay for the application of a skin substitute graft. You say that this service is documented in the records. The Plan denied your request. The Plan says that this was a non-graft dressing.  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 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.  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 application of a skin substitute graft. Our reviewer says that this code is supported in the records. Our reviewer found Integra acell skin substitute is not considered a non-graft wound dressing (eg, gel, powder, ointment, foam, liquid).  Therefore, code 15275 is appropriate to report for this service.  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 application of a skin substitute graft have been met. Therefore, we decided that the Plan has to pay for the application of a skin substitute graft (15275) provided on July 8, 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.