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

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency
transport, level 1 (A0427, A0425) provided on April 21, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say
that per the records provided the enrollee was transported from a dialysis center to the hospital emergency
room. The Plan denied your request. The Plan says there are no medical records to support the enrollee was
transported from dialysis to the hospital.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance service, advanced life support,
emergency transport, level 1. Our reviewer says that the ambulance transport was not medically necessary. Our
physician reviewer found that the presenting records did not clearly show the enrollee presenting with
symptoms that meet prudent layperson criteria for emergency care. The documentation does not support that
other means of transport were contraindicated. The documentation does not support that the enrollee required
expertise, services, or lifesaving treatment or equipment during transport. There was no evidence of the
enrollee requiring oxygen supplementation for clinical hypoxia. The documentation does not support that the
ambulance transport was 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 ambulance service, advanced life support, emergency transport, level 1 have not
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life
support, emergency transport, level 1 (A0427, A0425) provided on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from October 26, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 mental health care. Our physician reviewer found the admission does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 26, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any delusions, auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from October 26, 2021, forward
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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 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 pre-approve neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach (CPT code 62165) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you have had an enlargement of the pituitary since 2007. You state your provider suggests that you have surgery done at this facility due to the proximity to the carotid arteries. The Plan denied your request. The Plan says the are in-network providers that can provide the services.
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 neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach (CPT code 62165) to be provided by an out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital admission and
services provided from April 22, 2021, to April 26, 2021.
You asked the Plan to waive the coinsurance for the inpatient care. You say that this bill is outrageously high,
and you have never had to pay this much to stay in the hospital before. The Plan denied your request. The Plan
says the claim was processed correctly, and your cost-share 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 20%
coinsurance for inpatient hospital care.
You have been asked to pay 20% coinsurance for the inpatient care. The provider billed the Plan $12,280 for
the services at issue. The Plan's allowed amount for this care is $6,414.98. The Plan has paid their portion of
the cost, but you are responsible for 20% of the allowed amount ($6,414.98 x 20% coinsurance = $1,283). 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 coinsurance for the inpatient hospital admission and services provided from
April 22, 2021, to April 26, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-emergency ambulance transport (A0428) and ground mileage 
(A0425) provided on December 4, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance transport and mileage. You say that you could not 
sit up by yourself and could not stand up even with help. The Plan denied your request. The Plan says that your 
transportation home was not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable medical records from the 
emergency department visit and the transportation notes from the ambulance trip for this case. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided 
on December 4, 2020.  
 
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 the services provided to you by an out-of-network provider 
on June 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 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 services. Therefore, we 
decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on 
June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical 
history of stroke and atrial fibrillation and is living at home with episodes of falling and gait trouble. Medical 
problems are stable.

There are no complex nursing or rehabilitation needs. You do 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 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is to be used for the treatment of morbid obesity and obstructive sleep apnea syndrome (OSAS)/ obstructive sleep apnea syndrome (OHS). The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. The Plan states it is not apparent that the enrollee possesses a qualifying diagnosis for a home mechanical ventilator (HMV).
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 the home ventilator. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from obstructive sleep apnea. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a device is covered. 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 the home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from June 14, 2020, through
June 17, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
You asked the Plan to pay for inpatient services provided from June 14, 2020, through June 17, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says to support a diagnosis of Sepsis, the submitted documentation must demonstrate that there was "life- threatening organ dysfunction due to a dysregulated host response to infection.
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 the reported principal diagnosis A41.9, sepsis, unspecified organism. 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 services provided with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation does not support the diagnosis coded. There is no supporting documentation to link an infection to sepsis, as well as treatment for sepsis. The documentation states "1. Finding consistent with mild, asymmetric pulmonary edema and/or pneumonia most pronounced in the right lung base. 2. mild pleural reaction in the right hemithorax. 3. Stable borderline cardiomegaly. 4. CABG. 5. Pacemaker". There is not documentation to support coding sepsis as primary diagnosis or treatment of sepsis. Therefore, this diagnosis 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 services provided from June 14, 2020, through June 17, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucynta 100MG tablet, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee is stable on this medication and is the only medication relieving the enrollee's pain. The Plan denied your request. The Plan says this a self-administered drug and does not fall under Part B coverage. The enrollee does have other pharmacy benefits with another vendor, and they are not provided through Medicare or this Health Plan.
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 Nucynta 100MG tablet, for the enrollee.
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated abutment (D6056), and an implant/crown
(D6065) provided on August 3, 2021.
You asked the Plan to pay for a prefabricated abutment and an implant/crown. You say that this procedure was
authorized. You say that this should be covered fully. The Plan denied your request. The Plan says you have
already exhausted your benefit limit for these services. The Plan also says that prior authorization was not
obtained for service D6056.
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. The Plan covers a
prefabricated abutment when prior authorization is obtained and up to two implant/crown per calendar year.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a prefabricated abutment and an implant/crown have not been met. Specifically, evidence was
provided that showed two prefabricated abutments and implant/crowns were provided on April 22, 2021. This
means that you have exhausted the Plan benefit limit for implant/crowns in 2021. Therefore, we decided that
the Plan does not have to pay for a prefabricated abutment (D6056), and an implant/crown (D6065) provided
on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on April 29, 2021.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were billed without the appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that contractors shall accept FDG PET claims billed to inform initial treatment strategy with the following CPT codes AND modifier PI: 78608, 78811, 78812, 78813, 78814, 78815, 78816. We looked at the file and Medicare rules. In this case, code 78608 was billed without the appropriate (PI/PS) modifier. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from June 1, 2020 to June 5, 2020.
You asked the Plan to pay for the inpatient hospital care. You say that the medical records support DRG 871 with principal diagnosis code A41.9. The Plan denied your request. The Plan says the medical records do not support DRG 871 with principal diagnosis code A41.9.
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 871 with principal diagnosis code A41.9. 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 care. Our reviewer says that the medical records do not support DRG 871 with principal diagnosis code A41.9. Our physician reviewer found the member presented with shortness of breath. Appeal letter notes fever, tachycardia, and tachypnea. Though T100.8 and heart rate (HR) 97 are noted upon presentation, these values promptly improved with treatment in the emergency department (ED). Member is noted to be alert and oriented x3. Sepsis is noted secondary to aspiration pneumonia. Member was given IVF and antibiotics. Blood culture was negative. The record did not show significant or persistent hemodynamic instability, cognitive impairment or end-organ dysfunction that would be consistent with multi-system involvement due to sepsis. The review indicates that the medical records do not support the billing of - A41.9: Sepsis, unspecified organism as principal diagnosis. 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 the inpatient hospital services provided from June 1, 2020 to June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 necessitating admission to a LTACH. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. There are no services available 
at the LTACH that you require 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 your diagnosis 
and condition 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 LTACH services.