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

We decided that the Plan does not have to pre-approve nasal radiofrequency ablation services.
You asked the Plan to pre-approve nasal radiofrequency ablation. You say that this procedure is medically
reasonable and necessary for your condition. The Plan denied your request. The Plan says this procedure is not
covered by Medicare or the Plan.
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 nasal radiofrequency ablation. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the record indicates that the enrollee has chronic nasal obstruction
symptoms. The record provided does not indicate that the requested service is at least as effective as other
treatments. The record provided does not establish the medical necessity and reasonableness, as defined by
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nasal radiofrequency ablation have not been met. Therefore, we decided that the
Plan does not have to pre-approve nasal radiofrequency ablation services.
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 alternate settings can be requested, such as skilled nursing facility, outpatient setting, or
home health care.
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 based on the medical records provided, 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 do not require an intensive rehabilitation therapy program. There is concern that you
wouldn't be able to fully participate in and benefit from the intensive program provided in an inpatient
rehabilitation facility due to your limited tolerance for therapy as documented in the hospital records. Care at
the skilled nursing facility level appears to be 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the out-of-network office visit. You say that the out-of-network office visit
is medically necessary. The Plan denied your request. The Plan says there are multiple in-network providers
that can provide the services at issue.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office
visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested, such as a skilled nursing facility, outpatient setting, or home health care.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for elective total hip replacement and was discharged to skilled nursing on 12/17/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulation (PNS) device.
You asked the Plan to pre-approve an auricular PNS device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that the service for auricular peripheral nerve stimulation (CPT code 64999) will be denied as non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an auricular PNS device have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulation (PNS) device
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits.
You asked the Plan to pre-approve home health physical therapy visits. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health physical therapy visits.
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the
medical records provided there is no documentation that skilled therapy services are required to effectively
provide treatment, care, and/or services in order to improve the enrollee's level of function, or to
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent
deterioration. Records do not document objective measures of deficits with ambulation or transfers to justify
the physical therapy services requested.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued office visits and pulmonary tests with an out-
of-network (OON) provider.
You asked the Plan to pre-approve continuation of care with OON provider. You say that this care with an
OON provider continues to be medically necessary. The Plan denied your request. The Plan says there are in-
network providers that would be available for the enrollee's medical needs.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
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 continuation of care with OON
provider. Our reviewer says that the requested services are not medically reasonable and necessary. Our
physician reviewer found that the patient is a 70-year-old female former smoker with interstitial lung disease
with predominant ground glass opacity, lower lobe fibrosis, and no sub-pleural sparing currently requiring 2L
NC oxygen supplementation at rest being treated with nintedanib 100 mg BID, steroids, bronchodilators, and
pulmonary rehab. She obtains periodic computed tomography chest imaging. She is seeing a pulmonary and
critical care doctor that is OON for these services. There is a request for office visit and pulmonary test with
OON provider. There was no indication from the provided records that this patient could not be effectively
managed by an in-network pulmonary specialist continuing the treatment already initiated. Therefore, the
medical records do not support that the continuity of care with the current OON provider is medically
reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of care with OON provider have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued office visits and pulmonary tests with an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest 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 this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is no report in the submitted records of prior CT scan of the chest. Thus, the reason given for the request of follow-up pulmonary nodule cannot be confirmed. Also, if a follow-up scan is necessary a conventional CT of the chest, CPT 71250 would be more appropriate. Medical necessity of the requested CT scan cannot be established with the information provided.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G5-V7 provided from June 2, 2021 to June 30, 2021.  You asked the Plan to pay for codes J0604-AX and 90999-G5-V7. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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.  In this case, the CPT Code Manual definition of code J0604 is Cinacalcet, oral, 1 mg, (for esrd on dialysis). The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient.  We find that CPT codes J0604-AX and 90999-G5-V7 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of codes J0604-AX and 90999-G5-V7 have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G5-V7 provided from June 2, 2021 to June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on August 12, 2021.  You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.  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, we have confirmed that 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) 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 services (A0427) provided on September 14, 2020.  You asked the Plan to waive the copayment for ambulance transportation. You say that the services should be covered as you will not be paying for them. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $310 copayment for Ambulance services, regardless of if you are admitted to the hospital.    You have been asked to pay a $310 copayment for ambulance transportation. 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 services (A0427) provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on August 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on August 16, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda (J9271).  You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our reviewer says that Keytruda is not medically necessary. Our physician reviewer found Keytruda is approved for first-line, single-agent treatment of non-small cell lung cancer (NSCLC) in patients with stage III NSCLC (who are not candidates for surgical resection or definitive chemoradiation), or in patients with metastatic NSCLC, and with tumors with PD-L1 expression. The enrollee's tumor has a PD-L1 expression of less than 1%.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services provided on June 25, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered are not a covered benefit.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for the laboratory services by a contract provider. The contract provider ordered this testing. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services provided on June 25, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a biopsy of the esophagus, stomach, and/or upper small bowel using a flexible endoscope (43239) provided on June 11, 2021.  You asked the Plan to waive the copayment for the endoscopy. You say that you are retired and cannot afford to pay the bill. The Plan denied your request. The Plan says the cost-share was applied correctly.   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 $295 copayment for Outpatient Surgery.  You have been asked to pay a $295 copayment for an endoscopy. Endoscopies falls within the Outpatient Surgery benefit category. You received the procedure in an outpatient hospital setting. 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 biopsy of the esophagus, stomach, and/or upper small bowel using a flexible endoscope (43239) provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for hospital observation care provided from August 1, 2021, to August 6, 2021.  You asked the Plan to waive the copayment for the hospital observation care. You say that you feel you were an inpatient and should not be billed for observation. 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 $50 copayment for emergency services, including observation.   The medical records show your stay was outpatient observation. You have been asked to pay a $50 copayment for the hospital observation care. Hospital observation care falls within the Outpatient Hospital 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 hospital observation care provided from August 1, 2021, to August 6, 2021.