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 these services are medically necessary. The Plan denied your request. The Plan says that your records do not show that you need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a hip fracture after a fall. Your 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominal binder, belt, strap, sleeve, garment, or covering, any type (A4467).
You asked the Plan to pre-approve an abdominal binder. You say that you have received this item before and did not have to pay and it was not denied. You do not understand why it is being denied now. The Plan denied your request. The Plan says the requested abdominal binder not covered by Medicare or the Plan. While an abdominal binder is not covered, the plan has approved the more appropriate peristomal hernia support belt.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the abdominal binder have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominal binder, belt, strap, sleeve, garment, or covering, any type (A4467).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemotherapy drugs and administration (96375, 96413, 96415, J9312) provided March 12, 2021 to March 26, 2021.
You asked the Plan to waive the copayment for the chemotherapy drugs and administration. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $325 copayment for outpatient hospital services and a 20% coinsurance for Part B drugs. You have been asked to pay a coinsurance of 20% of the allowable amount for the drugs which fall in the Part B drugs category. The allowable amount for the chemotherapy administration, which falls under outpatient hospital services, was $43.95 per service.
This amount is less than the $325 copayment listed in the plan contract. For this reason, a copayment of $43.95 was applied per chemo administration. A total cost sharing (20% coinsurance for the drugs, plus two $43.95 copayments) is $2,955.33. 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 chemotherapy drugs and administration (96375, 96413, 96415, J9312) provided March 12, 2021 to March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve Transcatheter mitral valve implantation (TMVI) with prosthetic valve including associated procedure and hospital inpatient admission for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that transcatheter mitral valve replacement by means of the Edwards-Sapien valve is considered experimental and investigational because it has not been proven safe and effective for this indication.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Although data on use of the Edwards Sapien 3 valve for percutaneous mitral repair is more limited at present, this patient has failed open surgical repair and is not considered a viable repeat surgical candidate for mitral replacement owing to her prior surgeries, co-morbidities and advanced age. She remains symptomatic despite medical therapy with severe mitral insufficiency on recent echocardiography. She has been carefully evaluated by the structural heart team by both non-invasive and invasive cardiologists involved along with the cardiac surgery team and with shared decision making per established clinical guidelines. The Edwards Sapien 3 valve is also approved by FDA for use in mitral insufficiency where open surgery is felt to be too high risk as it is in this situation. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Transcatheter mitral valve implantation (TMVI) with prosthetic valve including associated procedure and hospital inpatient admission 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on April 16, 2021.

You asked the Plan to pay for the services provided. You say that the medical records illustrate the need for services. The Plan denied your request. The Plan says a corrected claim is needed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. We find that the services at issue were billed with a diagnosis of R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction. We find that Codes for symptoms, signs, and ill-defined conditions are not to be used as principal diagnosis when a related definitive diagnosis has been established. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on April 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination provided on July 24, 2019.
You asked the Plan to pay for radiologic examination, eye, for detection of foreign body (70030). You say that the claim was corrected. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for radiologic examination, eye, for detection of foreign body (70030) was not filed until April 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the radiologic examination provided on July 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 13, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the enrollee had to have sutures removed by the surgeon that placed them. The Plan denied your request. The Plan says the services were not urgent, emergent, nor 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 13, 2021 by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DyAnsys nerve stimulator.
You asked the Plan to pre-approve a DyAnsys nerve stimulator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the item is not a covered benefit under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a DyAnsys nerve stimulator have not been met. Specifically, the requested item is an electro-acupuncture device, which is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a DyAnsys nerve stimulator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for skilled nursing services provided by an out-of-network provider on
April 14, 2021.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says that prior authorization was not obtained.

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. a 2021 Evidence of Coverage was not provided. Therefore, we decided that the
Plan has to pay for skilled nursing services provided by an out-of-network provider on April 14, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has Alzheimer's disease.
She has been prescribed Donepezil since 2018 and is tolerating this medication. The enrollee's mini-mental
state exam (MMSE) was scored 27 out of 30 on July 6, 2020, and 29 out of 30 on March 25, 2021. Both results
are consistent with normal cognition. The records are insufficient to support that Aduhelm is reasonable and
medically necessary for the enrollee. It has not been shown that Aduhelm is at least as beneficial as the existing
and appropriate medically appropriate alternative that this enrollee is taking. The medication is not considered
safe and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Aduhelm.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional routine transportation trips.
You asked the Plan to pre-approve the 6 additional routine transportation trips. You say that additional routine transportation trips are needed for you to get to your doctor appointments. The Plan denied your request. The Plan says the request exceeds your benefit limits.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way routine transportation trips per year.
We looked at your request, the records in the case file, and the rules. The records show that, at the time of your request, you have received coverage for 59 one-way routine transportation trips in the 2021 calendar year. Based on this information, we decided that the number of routine transportation trips being requested would exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 6 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lodging, meals and transportation provided May 10, 2021, to May 14, 2021.

You asked the Plan to pay for the lodging, meals and transportation. You say that you cannot physically drive back from appointments on the same day. The Plan denied your request. The Plan says the lodging is not covered because the medical services performed were not related to a transplant.

The Plan must follow Medicare rules. Medicare rules say that the Plan provides transplant services at a location outside of the pattern of care for transplants in your community and you chose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion. 

We looked at the file and Medicare rules. In this case the record shows that the Plan contacted your doctor who indicated that the medical services provided were not transplant related and are instead related to a new episode of care related to cardiology.

Based on this information, we decided that Medicare rules for coverage of the lodging, meals and transportation have not been met. Therefore, we decided that the Plan does not have to pay for the lodging, meals and transportation provided May 10, 2021, to May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on September 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and paid. 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 wound care provided on September 1, 2020 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 transfer to an LTACH is medically necessary for this enrollee, and they cannot get the same services at a lower level of care. The Plan denied your request. The Plan says the enrollee is currently receiving appropriate acute care and does not require a transfer to an LTACH.
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 enrollee appears to be improving and only requires short-term additional acute care services for stabilization which can be safely provided at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, the request for a transfer to an LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 26, 2021.

You asked the Plan to pay for the services provided. You say that the codes are separately payable. 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. 

We looked at the file and the rules. We find that CPT codes 88341 and 83342 are payable when billed with an appropriate modifier. The claim provided does not show the services were billed with a payable modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services provided on April 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were in dire need of care. The Plan denied your request. The Plan says there is no authorization on file.
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 services. Therefore, we decided that the Plan does not have to pay for the psychiatric services provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve allograft (20930), autograft for spine surgery only (20936), arthrodesis (22612, 22614), posterior segmentation (22842), laminectomy (63047, 63048).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these services are not supported.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no instability, fracture, or lesion documented. Spine fusion surgery is not needed. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve allograft (20930), autograft for spine surgery only (20936), arthrodesis (22612, 22614), posterior segmentation (22842), laminectomy (63047, 63048).