Persius/hicric huggingface dataset:
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 enrollee requires daily physician visits, prolonged oxygen weaning, and intravenous antibiotics. You say that the enrollee requires too high a level of care to be provided at a skilled nursing facility but is stable enough for transition to an LTACH. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can stay in the hospital where she is now.
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 indicating medical necessity for 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 acute care hospital where she 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. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Zioptan drops.

You asked the Plan to pre-approve Zioptan. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Zioptan drops.

Benefits for Zioptan may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyaluronan and methylprednisolone acetate injections.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that hyaluronans are covered when specific criteria
are 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
the services are not medically necessary.
Our physician reviewer found the enrollee has primary osteoarthritis of the left knee. The records do not show that he has tried and failed other conservative treatments related to the pain and there is no evaluation of any other treatment modalities. The documentation provided does not include a history and physical examination to substantiate the need for the treatment. The requested hyaluronan and methylprednisolone acetate injections are not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyaluronan and methylprednisolone acetate injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care from June 6, 2021, to June 8, 2021.

You asked the Plan to pay for post stabilization care. You say that treatment of the enrollee in an inpatient setting was medically necessary. The Plan denied your request. The Plan says the enrollee was stabilized on June 6, 2021, and should have been considered for transfer to an approved facility.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 post stabilization care. Our reviewer says that the post-stabilization care services provided June 6, 2021, to June 8, 2021, at the non-contracted facility were not medically necessary or reasonable. Our physician reviewer found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility after the emergency room evaluation on June 6, 2021. The enrollee was admitted to the non-contracted facility on June 6, 2021. The Plan was not notified until after the admission on June 6, 2021. Authorization was not requested for the admission. The health plan made several attempts to request clinicals from the hospital. Clinicals were not received until June 8, 2021, the day of discharge. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. The post-stabilization care services from June 6, 2021, to June 8, 2021, were not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care from June 6, 2021, to June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. The patient appears to be unstable and requires additional short-term acute care hospital services that can safely be administered at the current facility for the time being. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on July 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore,
we decided that the Plan does not have to pay for the drug testing services (G0482) provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 27, 2020.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Inpatient hospital care.

You have been asked to pay a 20% coinsurance for the inpatient hospital care (total allowed is $303.69 x 20% = $60.74). 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 August 27, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Feraheme (Q0138).
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the
enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested drug have
not been met.
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 Feraheme. Our reviewer says that the
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the
requested use of Feraheme is FDA-approved for the enrollee's diagnosis. The enrollee is iron deficient on oral
iron but still has low stores with symptoms of restless leg as elderly patients don't absorb oral iron well. The
documentation supports 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 Feraheme have been met. Therefore, we decided that the Plan has to pre-
approve treatment with Feraheme (Q0138).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on August 6, 2021.
You asked the Plan to waive the copayment for the EKG. You say that you were supposed to have a treadmill stress test, but your blood pressure was too high. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($13.79) is less than your copayment obligation, you are responsible for the full allowed 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 non-radiological diagnostic tests. You have been asked to pay a $30 copayment for the EKG. The EKG falls within the non-radiological diagnostic tests 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 the electrocardiogram (EKG) you had on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 14,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by Medicare coding regulations.
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 99100 is "Anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)."
We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment
for other services not specified. Based on this information, we decided that Medicare rules for coverage of the
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services
provided to the enrollee on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (49083) provided on September 28, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

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 code 76942 is a column II code to column I code 49083. 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 services (49083) provided on September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head.
You asked the Plan to pay for MRA services. You say that you would like this claim reprocessed for medical
necessity. The Plan denied your request. The Plan says an appropriate modifier was not billed as required.
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 code 70544
is a column II code to column I code 70551. 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 magnetic resonance angiography (MRA) of the head.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TMS retreatment (CPT code(s): 90867, 90869, and 90868), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the information the Plan has about the enrollee's condition, the enrollee does not meet the requirement.

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 services. Our physician reviewer found based on review the records provided and utilizing the Medicare local coverage determination LCD specifically for transcranial magnetic stimulation (L37088) specifically states the confirmation of the diagnosis of Severe Major Depressive Disorder Single Or Recurrent and one or more of the following resistance to treatment with psychopharmacologic agents as evidenced by a lack of clinically significant response to for trials of psychopharmacologic agents in the current depressive episode from at least two (2) different agent classes. At least one (1) of the treatment trials must have been administered and an adequate course of mono or polydrug therapy or inability to tolerate psychopharmacologic agents as evidenced by four (4) trials of psychopharmacologic agents for at least 2 different agent classes, with distinct side effects or history of response to TMS may previous depressive episode or if the patient is currently receiving electroconvulsive therapy (ECT), TMS may be considered reasonable and necessary as a less invasive treatment option. The patient PHQ 9 is currently found to be 13 January 18, 2022.

The enrollee had been tried on Celexa and Seroquel which they were unable to tolerate a higher dose. The enrollee must show 50 percent improvement to prior treatment with a pre-and post-score on the enrollee's PHQ 9 which was not addressed in the documentation other than stating the enrollee had an improvement of 50 percent. Based on the information provided, this enrollee does not meet the clinical criteria for the use of TMS therapy utilizing LCD (L37088) as they have not taken medication as outlined above during the current episode of depression. The enrollee has not shown improvement of 50 percent as their PHQ 9 as there is no documentation showing improvement and this enrollee does not meet the criteria for major depressive disorder, recurrent, severe but rather by based on the PHQ 9. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve TMS retreatment (CPT code(s): 90867, 90869, and 90868), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), pulp
vitality tests (D0460), additional intraoral periapical x-ray (D0230), bitewing x-ray (D0270), and to pay more
for the resin-based composite (D2394) provided on October 13, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, additional
intraoral periapical x-ray, bitewing x-ray, or pay more for the resin-based composite. You say that you do not
have out of pocket money to cover the endodontist work and the crown as well. The Plan denied your request.
The Plan says the cone beam CT capture and interpretation and pulp vitality tests are not covered expenses
under your dental plan. The Plan says that your benefits for the additional intraoral periapical x-ray and
bitewing x-ray have been satisfied and the frequency limitations have been exceeded. The Plan also says that
when you contacted the Plan you were advised that your coverage is code specific, and you have an annual
maximum of $2,000.
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 cone beam CT capture and
interpretation (D0364) and pulp vitality tests (D0460) are not among those covered under this benefit. The
contract says that bitewing x-rays are limited to one set per calendar year. The record shows that you received
bitewing x-rays (D0272) on April 28, 2021 and your bitewing x-rays benefit has been exhausted. The Plan
contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that
you received a first intraoral periapical x-ray (D0220) on October 13, 2021 and your intraoral x-rays benefit
has been exhausted. The contract also says that the Plan offers a $2,000 annual dental benefit maximum. The
record shows that you met the annual maximum benefit on October 13, 2021 and your annual maximum
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam CT
capture and interpretation (D0364), pulp vitality tests (D0460), additional intraoral periapical x-ray (D0230),
bitewing x-ray (D0270), and to pay more for the resin-based composite (D2394) provided on October 13, 2021.
Your complaint about the misinformation you were given by the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a family
practitioner on June 9, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you thought you were just going
in for your annual visit, so there should be no copayment. The Plan denied your request. The Plan says you
received services on this date beyond an annual visit, so the copayment applied correctly. The Plan says that
you are only responsible for a $10 copayment for this visit.

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 $10
copayment for visits with a primary care provider.

Your Evidence of Coverage states that an annual wellness visit has no cost sharing. However, if you receive services that address a medical condition during the same office visit, additional cost sharing may apply. We looked at the medical records from this visit to determine if you received additional services to address a medical condition. The records show that in addition to the annual wellness visit, you were evaluated for hypertension and the dosage of your medication was changed. As such, you received services that address a medical condition. In accordance with your contract, your Plan is allowed to charge a copayment for that. You have been asked to pay a $10 copayment for the office visit. 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 the office visit you had with a family practitioner on June 9, 2021.