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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 you are more stable now but require additional short-term acute care services including weaning trials that can be safely completed at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.    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 waive the coinsurance for Medicare Part B drugs provided from July 23, 2021, to August 13, 2021.  You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that the services were approved and you do not understand why the charges are not being covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.   You received Medicare Part B drugs from July 23, 2021, to August 13, 2021. Therefore, you are responsible to pay 20% of the total allowed amount. However, you are only being asked to pay $1,609.38, which is less than the 20% coinsurance amount.   You have been asked to pay the total amount of $1,609.38 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from July 23, 2021, to August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids, contralateral routing device, monaural, in the canal (V5172) provided April 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the hearing aids. You say that you saw your ear, nose and throat doctor's audiologist and did not question whether he would be in-network. The Plan denied your request. The Plan says hearing aids provided OON are not covered.  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. The Plan covers the hearing aids when they are provided by the Plan's specified hearing aid provider.  We looked at the file and Medicare rules. In the case the hearing aids were not purchased from the Plan's specified hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, contralateral routing device, monaural, in the canal (V5172) provided April 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) and therapeutic injections/procedures (97750, 96372, 97112, J3411, J3490, J3415, J7999, 97016) provided August 30, 2021.  You asked the Plan to pay for electrical stimulation and therapeutic injections/procedures. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were incorrectly billed.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services by an NP or PA only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on a review of the file and publicly available records, we find that the physical therapy services at issue were rendered by a NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. 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 payable as billed, the drug administration code, 96372, also cannot be paid. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes. Based on this information, we decided that Medicare rules for coverage of electrical stimulation and therapeutic injections/procedures have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) and therapeutic injections/procedures (97750, 96372, 97112, J3411, J3490, J3415, J7999, 97016) provided August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient mental health care from January 20, 2022, forward.  You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee is a homeless combat veteran and disabled. The Plan denied your request. The Plan says the stay is not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient mental health care. Our physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 20, 2022, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors while being cooperative and compliant.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from January 20, 2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone marrow aspiration (20939) and exploration of spinal fusion (22830) provided on June 22, 2021.  You asked the Plan to pay for the bone marrow aspiration (20939) and exploration of spinal fusion (22830). You say that 22830 is a separate procedural service and an assistant was necessary due to severe complexity of the surgery. You say that the charges for these codes may be payable for an assistant with documentation of medical necessity and both codes should be reprocessed. The Plan denied your request. The Plan says CPT code 22830 cannot be reported with another procedure of the spine in the same anatomic area. The Plan also says that the records do not support CPT code 20939.  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 20939 is bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 22830 exploration of spinal fusion.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the bone marrow aspiration (20939) and exploration of spinal fusion (22830). Our reviewer says that the documentation was reviewed and does not meet the criteria for coverage. Our reviewer found that for CPT code 20939, the operative report does not include documentation of bone marrow aspiration for bone grafting. Our reviewer says that the operative report does not support reporting modifier 59 with CPT code 22830. The exploration of fusion should not be reported with another procedure of the spine in the same anatomic area.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone marrow aspiration (20939) and exploration of spinal fusion (22830) have not been met. Therefore, we decided that the Plan does not have to pay for the bone marrow aspiration (20939) and exploration of spinal fusion (22830) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on September 27, 2021, by an OON provider.  You asked the Plan to pay for the office visit. 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 an office visit provided on September 27, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 3, 2021.  You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you received approval to see an out-of-network provider. The Plan denied your request. The Plan says this service is not covered.  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 comprehensive periodontal evaluation (D0180) provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on May 4, 2021, by an OON provider.  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 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 referring provider 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 drug testing provided on May 4, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from November 10, 2020, to November 25, 2020.  You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you believe the Plan should pay the remaining balance. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 therapeutic radiological services, including technician materials and supplies.    Procedure/Item Allowed Amount 20% Coinsurance Radiotherapy Dose Plan IMRT - November 10, 2020 $1270.52 $254.10 (Adj to $111.84) SBRT Delivery - November 16, 2020 $1804.21 $360.84 SBRT Delivery - November 18, 2020 $1804.21 $360.84 SBRT Delivery - November 20, 2020 $1804.21 $360.84 SBRT Delivery - November 23, 2020 $1804.21 $360.84 SBRT Delivery - November 25, 2020 $1804.21 $360.84 Total:  $1916.04  You have been asked to pay $1916.04, which is less than 20% of the allowed amount for the radiation therapy services. Radiation therapy services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for radiation therapy services provided from November 10, 2020, to November 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Methotrexate tablets.  You asked the Plan to pre-approve the Methotrexate tablets. You say that due to the enrollee's age and other comorbidities, you do not want to switch her to a biologic such as Enbrel or Humira. You also say that you would like the denial reversed and coverage to be continued for the Methotrexate which the enrollee has been taking for the last 12 years and has been effective and tolerated by the enrollee. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.  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 Methotrexate tablets.   Benefits for the Methotrexate tablets 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 acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for syncope, neck contusion, and atrial fibrillation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra drops 5%.  You asked the Plan to pre-approve the Xiidra drops. You say that the Restasis was no longer working, and the provider wanted the enrollee to go to Xiidra. The Plan denied your request. The Plan says Xiidra drops 5% is a self-administered drug. The Plan also says that Xiidra does not fall under Part B coverage.  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 drops 5%.   Benefits for the Xiidra drops 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 1,000 total units of Venofer (J1756) over 60 days to allow 200 units per visit every other week for a total of 5 visits.  You asked the Plan to pre-approve the Venofer. The Plan denied your request. The Plan says the criteria for this service is not met.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and Drug Administration (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 the Venofer. Our reviewer says that this request for 1,000 total units of Venofer (J1756) over 60 days does not meet the coverage criteria. Our physician reviewer found the record indicates that the enrollee has a diagnosis of iron deficiency anemia from myelodysplastic syndrome. The FDA has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that the elements of the coverage criteria are not satisfied.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Venofer have not been met. Therefore, we decided that the Plan does not have to pre-approve 1,000 total units of Venofer (J1756) over 60 days to allow 200 units per visit every other week for a total of 5 visits.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the self-administered drugs rendered from July 2, 2021 to July 3, 2021.  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 self-administered drugs are not covered.  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 the self-administered drugs rendered from July 2, 2021 to July 3, 2021.   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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services rendered on May 11, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 20611 is not supported.  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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.  We find that CPT code 20611 is not supported in the medical record. Specifically, the records show that a knee injection without imaging guidance was performed and there is a more appropriate code for these services.      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 services rendered on May 11, 2021.
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 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 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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or a long-term care facility on a part time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.