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

 We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.  You asked the Plan to pre-approve a continuation of SNF care. You say that the records provided support the need for continued SNF care. The Plan denied your request. The Plan says continued SNF care is not medically necessary.  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 a continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The enrollee does not require skilled therapy services. The enrollee does not require services on an inpatient basis, only in a SNF setting. Services in the home with home care or in a long-term care facility on a part-time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergent ambulance services provided on May 10, 2020.  You asked the Plan to pay for the non-emergent ambulance services. You say that you would like reconsideration because you could not walk and called an ambulance. The Plan denied your request. The Plan says you did not meet Medicare criteria for coverage of the non-emergent ambulance services.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance services have not been met. Specifically, the record does not indicate that another means of transportation would be contraindicated for you. Additionally, the record suggests that you were told at the time of the service that this would not be covered. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance services provided on May 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Imfinzi (Durvalumab).  You asked the Plan to pre-approve the drug. You say that this is medically necessary based on the clinical information submitted. The Plan denied your request. The Plan says this is 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of  squamous cell carcinoma of the lung with PDL-1 expression of 21%. The record indicates that the enrollee is stage IVa. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi (Durvalumab).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspirate procedure.  You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee has weakness that is getting progressively worse. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not shown that this is helpful for the enrollee's condition.  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 bone marrow aspirate. 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. More research is needed to show its safety and efficacy when used as bone graft material.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate procedure.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH 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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.    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 pay for the retrobulbar injection rendered on May 12, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 67500 (retrobulbar injection) and 00140 (anesthesia for procedures of the eye). Code 67500 is a column II code with a modifier indicator of 1 when billed with column I code 00140. Code 67500 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the retrobulbar injection rendered on May 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) stay provided from July 13, 2021, to July 31, 2021.  You asked the Plan to pay for the continued SNF stay. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.  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 pay for the continued SNF stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the continued SNF stay have not been met. Therefore, we decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) stay provided from July 13, 2021, to July 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablet 5mg for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this medication was denied due to a benefit exclusion.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablet 5mg for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient care provided from June 7, 2021, to June 10, 2021.  You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that the enrollee did not meet the criteria for an inpatient admission and the need for the inpatient level of care is not supported.  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 the inpatient care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found at the time of inpatient admission the admitting physician reasonably expected that the patient'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 the inpatient care have been met. Therefore, we decided that the Plan has to pay for the inpatient care provided from June 7, 2021, to June 10, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral hygiene instructions (D1330 x 2) and scaling in the presence of gingival inflammation (D4346) provided from October 8, 2021, to November 8, 2021.  You asked the Plan to pay for the dental services. You say that you were billed $200 for cleanings that you received. You also say that you were advised the services would be covered. The Plan denied your request. The Plan says oral hygiene instruction is not listed as a covered service. The Plan says that scaling in the presence of gingival inflammation is not listed as covered either.  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.   Though the Plan offers a dental benefit in excess of Medicare coverage, the oral hygiene instructions and scaling in the presence of gingival inflammation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330 x 2) and scaling in the presence of gingival inflammation (D4346) provided from October 8, 2021, to November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a hereditary cardiovascular profile (81405, 81403, 81401, 81404) provided on August 21, 2021.  You asked the Plan to pay for a hereditary cardiovascular profile. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.  We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular profile have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular profile (81405, 81403, 81401, 81404) provided on August 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the blood platelet aggregation rendered on July 29, 2021 to July 30, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the use of the -59 modifier.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    We asked our coder 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 these services Our reviewer says that the submitted records do not support the use of the -59 modifier. Our coder reviewer found the records document a diagnosis of Z00.6 (encounter for examination for normal comparison and control in clinical research program) was billed for procedure code 85576. If Z00.6 is present on a claim, either modifier Q0 or Q1  must be appended to the clinical service (claim) for participants in a clinical research program within the previous or subsequent 30 days in order for the service to be considered for reimbursement.  As a result of the missing necessary modifier, 85576 26 59 is not eligible for reimbursement consideration.  We looked at this coder'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 pay for the blood platelet aggregation rendered on July 29, 2021 to July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.  You asked the Plan to pre-approve radiofrequency ablation of the SI joint. You say that you are in severe pain and it limits your daily activities. The Plan denied your request. The Plan says research has not proven the requested services to be helpful for the enrollee's condition. The Plan says that the requested injection services are considered experimental and investigational.  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 radiofrequency ablation of the SI joint. Our reviewer says that the requested injection services are not considered medically reasonable and necessary in this case.  Our physician reviewer found this is considered experimental and investigational because of the wide variation in efficacy reported in the literature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 12, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges. 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 $30 copayment for specialist visits.   You have been asked to pay a $30 copayment for a specialist visit. A specialist 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 copayment for a specialist visit provided on August 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 25, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed an angiogram you needed to be transported to a different hospital that could provide the service. 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 $225 copayment for each one-way ground ambulance trip. 

You have been asked to pay a $225 copayment for the ambulance transportation. Please note that according to the Plan contract, there are no cost-share waivers when transferring from one facility to another.

Ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuropathy treatments provided on September 9, 2021.  You asked the Plan to pay for the neuropathy treatments. You say that the neuropathy treatments provided on September 9, 2021, were medically necessary. The Plan denied your request. The Plan says the neuropathy treatments provided on September 9, 2021, were not medically necessary.  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 pay for the neuropathy treatments. Our reviewer says that the neuropathy treatments provided on September 9, 2021, were not medically necessary. Our physician reviewer found the services which were provided to the member in this case were not readily consistent with the generally accepted standards of practice/care.   The services under review are not readily recognized by any professional society as being safe and effective for use in the management of neuropathic pain. The services as provided to the member have not yet been demonstrated to have a meaningful impact on patient care or outcome. There is further study necessary of the technology. The service would be better defined as being investigational in nature. In as much these services would not have met the Medicare definition of medical necessity.  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 neuropathy treatments have not been met. Therefore, we decided that the Plan does not have to pay for the neuropathy treatments provided on September 9, 2021.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in home with services or in a skilled nursing facility with intermittent therapies.  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.