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

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you need ongoing care in an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. You are receiving medically necessary acute and/or critical care. You do not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage.  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 you have had a complicated hospital course including acute kidney injury and require ongoing acute care services. You continue to receive acute care at the current facility, and these services have not been denied. The record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist telehealth visits provided from August 25, 2021, to September 17, 2021.  You asked the Plan to waive the copayments for the specialist telehealth visits. You say that the calls last 5 minutes and should not be considered specialist visits. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each specialist visit, including telehealth visits.   You have been asked to pay a $45 copayment for each specialist telehealth visit, for a total of $90.   The specialist telehealth visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for specialist telehealth visits provided from August 25, 2021, to September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on February 11, 2021, to February 16, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was updated.  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 190 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee presented to the facility with dyspnea and weakness. The wound care nurse evaluated the enrollee and noted a stage 3 pressure injury to the right buttock. While the physician agreed with these findings, the attending physician did not document a description of the wound in the plan of care or discharge summary, nor was there an intelligible picture that permitted clinical validation of the presence of a stage 3 wound. The review has determined that the appropriate DRG is 191.   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 to the enrollee on February 11, 2021, to February 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 12, 2021.  You asked the Plan to pay for the ambulance service. You say that the emergency medical services (EMS) personnel advised you were not in immediate danger. You say that your sister felt that it was not necessary for you to go to the emergency room. You also say that this should be covered. The Plan denied your request. The Plan says when multiple ambulance providers respond, payment may be made only to the ambulance provider that furnishes the transport. The Plan says that since no transport was provided, there is not payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 12, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Orthovisc injections (J7324).  You asked the Plan to pre-approve Orthovisc. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug must be supplied by your medical provider or medical facility. The Plan says that the provider office confirmed that the requested drug will be supplied by a pharmacy.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Orthovisc injections (J7324).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record does not contain sufficient information to determine whether the coverage criteria are satisfied. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy provided on August 1, 2021, to August 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy provided on August 1, 2021, to August 30, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from September 30, 2019, through October 3, 2019, billed with secondary diagnosis code J96.21.  You asked the Plan to pay for the inpatient services as billed. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support a diagnosis of acute on chronic respiratory failure.  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 secondary diagnosis codes J96.21, defined as acute and chronic respiratory failure with hypoxia. 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 services as billed. Our reviewer says that the reported secondary diagnosis code is not supported by the records. Our physician reviewer found the patient maintained oxygen saturation in the 90s during the entire stay on 2 liters per minute of oxygen. The patient did not require treatment consistent with acute respiratory failure such as high flow oxygen administration, provision of bilevel positive airway pressure (BiPAP), and/or use of mechanical ventilation. The review has determined that did not the documentation support the reported secondary diagnosis code J96.21 (Acute and chronic respiratory failure with hypoxia).   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 care provided from September 30, 2019, through October 3, 2019, billed with secondary diagnosis code J96.21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and supplies.  You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and supplies.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says there is no applicable Centers for Medicare & Medicaid Services (CMS) guidance for the provider and enrollee's geography. The Plan states the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.    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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in spinal surgery. More research is needed.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH services have not been met.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on August 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that the rendering physician/provider is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the patient's insurance company. You also requested for the Plan to not penalize your provider for the hospital staff's failure in taking the proper steps to obtain authorization for these services. The Plan denied your request. The Plan says that a non-participating provider rendered the services and the Plan did not receive a primary care provider (PCP) referral to review and approve. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on August 20, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you need long term hospital care and would be best served in an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. It is not safe for you to leave the hospital at this time due to your unstable condition. You are receiving appropriate care in the current hospital and there is no advantage in transferring to an LTACH at this time.  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 the record indicates that you are improving but require ongoing acute care services, which have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for an ultrasound and a specialist office visit provided on July 8, 2021.  You asked the Plan to waive the copayments for an ultrasound and a specialist office visit. You say that you hit your maximum out-of-pocket (MOOP) so there should be no copayments applied. The Plan denied your request. The Plan says the enrollee hit there MOOP during the date of service. Therefore, the proper copayments were applied.  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 $25 copayment for Medicare-covered non-radiological diagnostic services and a $35 copayment for services obtained from a specialist. The amount allowed for the ultrasound was $9.64 which is less than the copayment amount of $25. The copayment charged for the specialist office visit was $35. The total amount for the copayments was $44.64.  The enrollee's contract with the Plan also says that enrollees will pay a maximum out-of-pocket (MOOP) amount of $4,500 for 2021. The MOOP prior to the date of service was $4,455.36. After the copayments of $44.64 the enrollee hit their $4,500 ($4,455.36 prior MOOP + $44.64 copayments) MOOP for the year of 2021.  You have been asked to pay a $9.64 copayment for an ultrasound and a $35 copayment for a specialist office visit. An ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for an ultrasound and a specialist office visit provided on July 8, 2021.