Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that you had complications after surgery that caused your incision to split open and your knee to become inflamed, prolonging your healing process. You say the treatment you have received prior has helped you to become stronger, but you feel that you still need more sessions to be strong enough to walk without assistance of a walker. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records you appear to have plateaued with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Transcatheter aortic valve replacement (TAVR) 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 that TAVR requires symptomatic aortic stenosis with tricuspid valves to qualify for this procedure.
The Plan follows Medicare rules. Medicare rules say that TAVR is covered if the NCD criteria has been met. 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 TAVR is medically reasonable and necessary for the enrollee. The patient has severe aortic stenosis and symptoms of dyspnea on exertion. He meets clinical criteria for the treatment of his stenotic aortic valve disease. Current rules require face to face evaluation of the patient by both the implanting cardiology physician and a heart surgeon which has been documented. Based on shared decision making with the patient, they have recommended TAVR therapy as treatment for his valvular heart disease using the Edwards Sapien FDA approved device. Although not studied in the initial randomized TAVR trials, FDA approval of this device for lower risk patients does not limit the use of TAVR based on the underlying valvular morphology. It only requires that the patient has symptomatic aortic stenosis and that it has been evaluated for clinical appropriateness by a multi-disciplinary heart team with the sufficient required expertise. This requirement has been met in this clinical situation. Our physician reviewer found that the enrollee's condition meets Medicare criteria for TAVR. 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 aortic valve replacement (TAVR) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 29, 2021, to June 1, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you are requesting reconsideration as you should not have to pay anything on this claim. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $250 copayment per day, for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $0 copayment per day, for days 6 to 90 for inpatient hospital care.

You have been asked to pay a $250 copayment per day for inpatient hospital care. The records show that you were inpatient for three (3) days ($250 x 3 days = $750). The EOC confirms that $250 per day is the required copayment for this service. 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 inpatient hospital care provided on May 29, 2021, to June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm treatments.

You asked the Plan to pre-approve treatment with Aduhelm. You say that the enrollee has mild cognitive impairment and would benefit from this drug to prevent worsening of her condition. The Plan denied your request. The Plan says the enrollee's testing does not show mild cognitive impairment at this time, nor is there imaging demonstrating amyloid plaques.

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 treatment with Aduhelm. Our reviewer says that the requested treatment with Aduhelm is not shown to be medically reasonable and necessary. Our physician reviewer found the documentation does not support that there has been a significant, steadily progressive cognitive decline from a previous level of performance, or that the enrollee has cognitive deficits that interfere with her daily living activities. In addition, the magnetic resonance imaging (MRI) in this case does not show evidence of significant white matter abnormalities, and there are no reported amyloid beta plaques. 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 treatment with Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 15, 2020, to December 31, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee had Coronavirus and was released two weeks prior. You also say the stroke was related to the enrollees Coronavirus diagnosis. The Plan denied your request. The Plan says the copayment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment per day, for days 1 to 6 for inpatient hospital care.

The enrollee has been asked to pay a $295 copayment per day for inpatient hospital care. The records show that this admission was for a stroke and although there is mention of the enrollee having Coronavirus in November, the notes state that was resolved at the time of this admission in December. The records show that you were inpatient for sixteen (16) days, therefore, your total cost share is for 6 days ($295 x 6 days = $1,770). The EOC confirms $295 per day is the required copayment for this service. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 15, 2020, to December 31, 2020.
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 this is medically necessary. The Plan denied your
request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical repair of a hip fracture after a fall. 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 medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 provided on April 4, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. The Plan denied your request. The Plan says ambulance transport after death is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of ambulance service, advanced life support, emergency transport, level 1 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on April 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on March 10, 2021.
You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied your request. The Plan says the documentation does not support this code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on this service is not documented in the records.. Based on this information, we decided that Medicare rules for coverage of
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on March 10, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and periodic oral evaluation (D0120) provided on March 4, 2021 and June 3, 2021.

You asked the Plan to pay for the periodontal maintenance and periodic oral evaluation. You say that the services should be covered since they were covered last year. The Plan denied your request. The Plan says the provider does not bill Medicare. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and periodic oral evaluation (D0120) provided on March 4, 2021 and June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99443) rendered by the out-of-network (OON) provider on April 22, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 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 this service. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service (99443) rendered by the out-of-network (OON) provider on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Injectafer infusion you received on April 2, 2021.

You asked the Plan to waive the coinsurance for the Injectafer infusion. You say that your infusions typically last four hours, but this one only lasted 15-20 minutes. You stated that because you didn't get the amount of medicine that you normally receive, that you should not have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan stated that they contacted your doctor and confirmed that you received the amount of medication that he prescribed with no substitutions.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Injectafer infusion. The Injectafer infusion. falls within the Medicare Part B drugs benefit category. This cost sharing applies regardless of how long the infusion lasts. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Injectafer infusion you received on April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on April 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that the services were supposed to be cancelled. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

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 the surgical services provided on April 27, 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 admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for sepsis, peritonitis and perforation of intestine. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a metabolic PET scan for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says a detailed history that shows why this study is needed was not provided.

The Plan must follow Medicare rules. Medicare rules say that PET 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 neurologist's note says that this scan has been requested to differentiate between FTD and Alzheimer's dementia, which would normally qualify the exam per Medicare guidelines. However, the clinical notes do not mention such a differential, and the clinical data submitted does not resemble those associated with FTD. Thus, the reason given by the neurologist for this scan qualifies, but the clinical information does not match. At this point, the medical necessity of this scan cannot be established. 

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 a metabolic PET scan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered from August 1, 2020 to August 19, 2020.
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 Plan must follow Medicare rules. Medicare rules say that drugs while rendered for the treatment of end-stage renal disease (ESRD) are not separately payable.
We looked at the file and Medicare rules. The file shows that the services at issue were drug services rendered for the treatment of ESRD. 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 drug services rendered from August 1, 2020 to August 19, 2020.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.