Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient hospital admission.  You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee was having chest pains and that the records provided support the need for an inpatient hospital stay. The Plan denied your request. The Plan says there is no need for the enrollee to stay in the hospital waiting for her next procedure.  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 pre-approve an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this case.  Our physician reviewer found the documentation does not support that at the time of the inpatient admission request the physician reasonably expected the enrollee's necessary hospital 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 an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee needs to be admitted due to COVID illness and decline. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided to the enrollee on May 7, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided to the enrollee on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for lead wires (A4557) for a transcutaneous electrical nerve stimulator (TENS) unit provided on September 29, 2021.  

You asked the Plan to pay for lead wires. You say that the requested item was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.  

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided medical records are from 2020 and do not discuss the need for the requested item. 

Therefore, we decided that the Plan does not have to pay for lead wires (A4557) for a transcutaneous electrical nerve stimulator (TENS) unit provided on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit (Q5106).  You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says based on Medicare coverage rules, ESA treatment is non-covered for the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that ESA treatment is not reasonable and necessary for beneficiaries with anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML).  We looked at the file and Medicare rules. In this case, the enrollee has been diagnosed with anemia associated with the treatment of AML. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 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 based on the documentation provided the enrollee appears to not be stable enough for transfer at this time.   Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  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 LTACH services.
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 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 do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 4, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe emergency visits are covered and think this claim may have been coded incorrectly. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.  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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 4, 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.  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 that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.    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 a pneumonia vaccine received on September 8, 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 rendering pharmacy is out-of-network.  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 a pneumonia vaccine received on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of home dialysis services with an out-of-network (OON) provider.  

You asked the Plan to pre-approve the continuation of home dialysis. You say that it is medically necessary for the enrollee to continue receiving this care from the OON provider. The Plan denied your request. The Plan says they have in-network providers that would be able to handle the enrollee's care needs.  

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees 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 the continuation of home dialysis. Our reviewer says that the requested continuation of care with the OON provider is not medically necessary. Our physician reviewer found the review indicates that the enrollee is a 36-year-old female with a history of end stage renal disease. The review has determined that the records received do not indicate that the enrollee has an emergent or urgent medical condition or is in need of specialized service not available in her network. There are in-network provider(s) within a reasonable distance from her location that can provide this service or item. The review has determined that it is not medically reasonable or necessary for the enrollee to continue receiving care from the OON provider.  

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 continuation of home dialysis have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of home dialysis services with an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head (70544) provided on September 17, 2021.  You asked the Plan to pay for MRA of the head. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed with this claim.  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 70533. 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 magnetic resonance angiography (MRA) of the head (70544) provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient office visit (99212) therapeutic procedures (97150) unlisted therapeutic procedure (97139) injection of drug/substance under skin or into muscle (96372) unclassified drugs (J3490) provided on March 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered under Medicare or the Plan. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. 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 outpatient office visit (99212) therapeutic procedures (97150) unlisted therapeutic procedure (97139) injection of drug/substance under skin or into muscle (96372) unclassified drugs (J3490) provided on March 24, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910), localized delivery of antimicrobial agents (D4381), drugs or medicaments dispensed in the office for home use (D9630), and five resin-based composites (D2391 x5) provided on September 1, 2021.  

You asked the Plan to pay for the periodontal maintenance, localized delivery of antimicrobial agents, drugs or medicaments, and resin-based composites. You say that the provider received an insurance verification stating you had 100% coverage for diagnostic preventive and basic services. You also say that you would like the Plan to pay the 100% that was indicated on the insurance verification. The Plan denied your request. The Plan says the periodontal maintenance, localized delivery of antimicrobial agents, and drugs or medicaments are not covered expenses under your dental plan. The Plan also says that your restorations benefit has been satisfied and the frequency limitation has been exceeded.  

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 periodontal maintenance (D4910), localized delivery of antimicrobial agents (D4381), and drugs or medicaments dispensed in the office for home use (D9630) are not among those covered under this benefit. The contract says that restorations (fillings) are limited to two procedure codes per calendar year. The record shows that you received seven resin-based composites (D2391 x7) on September 1, 2021, two of which were covered by the Plan, and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), localized delivery of antimicrobial agents (D4381), drugs or medicaments dispensed in the office for home use (D9630), and five resin-based composites (D2391 x5) provided on September 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided July 23, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you cannot afford the cost of the service. The Plan denied your request. The Plan says the copayment 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 $280 copayment for each Medicare-covered one-way trip via ground ambulance.   You have been asked to pay a $280 copayment for the emergency ambulance services. The emergency ambulance services fall 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra eye drops.  You asked the Plan to pre-approve Xiidra. You say that the enrollee has failed Restasis and Systane eye drops. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 Xiidra eye drops.   Benefits for Xiidra 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 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 that you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. 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 LTACH services.