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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need to get stronger. The Plan denied your request. The Plan says you have no skilled nursing needs, and no acute skilled therapy needs.  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 physician reviewer found that from a nursing perspective, you received oral medicaitions, had stable vital signs, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a contact guard to minimal assist level for transfers. You remain non-weight bearing to your right lower extremity. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on February 18, 2021.  You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained.    The submitted claim form indicates the laboratory specimen was obtained in a laboratory setting, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 24, 2021.  You asked the Plan to pay for the office visit provided by a chiropractor. You say that this service is covered under your wife's Plan so you feel it should be covered. The Plan denied your request. The Plan says the services received are not a covered benefit.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 7, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says based on Medicare coverage guidelines, the request for non-emergency ambulance transportation from the hospital to place of residence does not meet criteria for approval.  Medicare pays for ambulance services only when they are medically reasonable and necessary. 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, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the record indicates that the enrollee was transported from the hospital to her residence after being hospitalized for chronic obstructive pulmonary disease exacerbation. The record indicates that the enrollee was transported via stretcher. The record does not indicate that the enrollee's clinical condition is such that other methods of transport are contraindicated or that the enrollee required the services of ambulance personnel. 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says Injectafer for iron deficiency without anemia is not supported.  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 Injectafer. Our physician reviewer found that the enrollee has recurrent iron deficiency anemia and secondary polycythemia. The requested use of Injectafer is not FDA-approved for the enrollee's diagnosis. The drug is approved for intolerance to oral iron.  There is no documentation of this intolerance. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency room services or overnight services provided on July 31, 2021.  You asked the Plan to pay for the emergency room services and overnight services. You say that the enrollee was seen twice on the same date of service at two different times and by two different providers. The Plan denied your request. The Plan says code 99284 is part of a code pair, and the other code of the pair has already been paid. The Plan also says that code 99053 has been designated as status B and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that payment for a code with a status indicator of B is always bundled into payment for other services.  In this case, we have confirmed that code 99284 is a column II code to column I code 99220. This claim has not been billed with an appropriate modifier to bypass the edit. These codes were billed by physicians in the same billing group and with the same specialty. We have also confirmed that code 99053 has a status indicator of B. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services or overnight services provided on July 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor supplies provided on June 9, 2021.  You asked the Plan to pay for the continuous glucose monitor supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply code.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that the documentation submitted did not sufficiently support the billed supply code. The documentation did not indicate that the provider discussed the need for the billed supply code. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies provided on June 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 23, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. 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, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  Our physician reviewer found that the record indicates that the enrollee was transported from a hospital out-patient visit to private residence by stretcher. The record indicates that the enrollee has a history of cancer and weakness. The record indicates that the enrollee was transported via stretcher. The record does not indicate that the enrollee's clinical condition is such that other methods of transport, such as stretcher van, were contraindicated. 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from March 3, 2021, through March 5, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the medical record did not show that at the time of the inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 3, 2021, through March 5, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies (K0553) provided on March 25, 2021.  You asked the Plan to pay for the CGM services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says sufficient documentation was not provided to pay the claim.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the provider has not discussed the medical necessity of the provided equipment with the enrollee per the submitted records. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies (K0553) provided on March 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided from September 30, 2021, to November 8, 2021.  You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you were not aware of the charges prior to receiving the services and would not have gotten physical therapy if you had known ahead of time. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for outpatient rehabilitation services.   You received outpatient rehabilitation services from September 30, 2021, to November 8, 2021, for a total of 3 visits. Therefore, you are responsible to pay the total amount of $103.85, which is less than the total copayment amount.   You have been asked to pay the total amount of $103.85 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided from September 30, 2021, to November 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 6, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that you did not want to be around Coronavirus patients, and you did not want to go to hospital. You say that you did not realize that refusing transport would result in a denial of a claim. The Plan denied your request. The Plan says the Medicare guidelines say the Medicare ambulance benefit is a transportation benefit and without a transport there is no 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 August 6, 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 ambulance response and treatment, no transport (A0998) provided on August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment and coinsurance for a nuclear stress test and radiological test supplies provided on October 25, 2021.  You asked the Plan to waive the copayment and coinsurance for the stress test and supplies. You say that you were informed by the Plan that you would only have a $45 copayment. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $275 copayment for advanced imaging services provided at an outpatient hospital.   Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies.  You have been asked to pay a $275 copayment for the stress test. You have also been asked to pay $2, which is 20% of the allowed amount for the test supplies ($10 allowed amount x 20% coinsurance = $2). The total for the procedure is $277. The stress test and supplies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 and coinsurance for a nuclear stress test and radiological test supplies provided on October 25, 2021.   Your complaint about the Plan representative informing you of a different copayment amount is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 you need continued therapy to get better. The Plan denied your request. The Plan says your needs are considered custodial.  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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you remain non-ambulatory and require a mechanical lift for transfers. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your request. The Plan says this use of this drug is not supported.  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 Aduhelm. Our reviewer says that the requested use of Aduhelm is not supported. Our physician reviewer found Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. There is no documentation of a Mini-Mental State Examination (MMSE) in this case. In addition, the imaging in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. Lastly, it has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your pain is not localized.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.   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 requested services. Our physician reviewer found that in this case, you have low back pain with radicular pain, which is not consistent with facet pain. There is radiating pain into the lower extremities, for which facet interventions are not supported. The review has determined that you do not meet the coverage criteria.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.