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

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the documents fail to show that you meet the Medicare Part A criteria for a SNF stay. The Plan states the records do not show a daily rehabilitation requirement. The Plan states wound care is not complex and intravenous (IV) Vanco treatment both can be arranged at a lower level of care (i.e. at your home). The Plan states based on the information provided the care needed is considered custodial and custodial care is not covered under the Medicare Part A (inpatient stay) benefit.  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 you do qualify for SNF coverage. You do have documented skilled nursing needs, as you are to receive daily intravenous (IV) antibiotics for 4-6 weeks. You do not have documented skilled therapy needs, as you appear to be functioning at/near you baseline. Daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition. Given the duration of this daily need and current shortages in healthcare staffing, it is likely that attempts to provide these services at home will result in days of missed services. Therefore, as a practical matter, the services cannot be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital stay provided from December 26, 2020, to January 13, 2021.  You asked the Plan to pay for the inpatient hospital stay. The Plan denied your request. The Plan says the enrollee has exhausted their maximum Medicare Inpatient benefit.  The Plan must follow Medicare rules. Medicare rules say that Part A benefits allow for 60 lifetime reserve days for use after a 90-day benefit period has exhausted. The 60 days are not renewable and may be used only once during a beneficiary's lifetime.   We looked at the file and Medicare rules. The Plan covers 60 "lifetime reserve days the enrollee can use if their hospital stay is longer than 90 days. The contract says that once the extra 60 days have been used up, the inpatient hospital coverage will be limited to 90 days. The record shows that the enrollee exhausted their maximum benefit on December 26, 2020. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital stay provided from December 26, 2020, to January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for immune gamma-globulin injections coded as 96365, 96366, J1569 provided September 11, 2021.  You asked the Plan to pay for the infusion services. You say that please review attached medical records supporting diagnosis and medical necessity for the charges billed. The Plan denied your request. The Plan says the records do not support that the requested IVIG therapy is medically reasonable and necessary.  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 pay for the infusion services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the requested drug is prescribed for suspected seronegative autonomic ganglionopathy. The record indicates that the enrollee has L2/L3 diskitis and possible osteomyelitis. These are not conditions listed in the coverage determination. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  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 infusion services have not been met. Therefore, we decided that the Plan does not have to pay for immune gamma-globulin injections coded as 96365, 96366, J1569 provided September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient office visit (99212) therapeutic procedure (97110) therapeutic activities (97530) provided September 27, 2021.  You asked the Plan to pay for the outpatient services. You say that please review the claim and records in their entirety and apply the appropriate payment for the professional services rendered. The Plan denied your request. The Plan says this is an administrative determination for lack of medical documentation and is not based on clinical criteria for medical necessity.  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 find that CPT codes 99212, 97110 and 97530 are not supported in the medical record. Specifically, there were no medical records provided. The Plan made multiple attempts to obtain the medical records from the provider without success. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99212) therapeutic procedure (97110) therapeutic activities (97530) provided September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585).  You asked the Plan to pre-approve onabotulinumtoxina. You say that there is literature to support that the requested drug is safe and effective for the enrollee's diagnosis. The Plan denied your request. The Plan says the onabotulinumtoxina is not approved by the FDA for the enrollee's diagnosis.  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 onabotulinumtoxina. Our reviewer says that onabotulinumtoxina is not medically necessary. Our physician reviewer found the provided records and the Medicare-approved major drug compendia do not indicate that the requested use of onabotulinumtoxina is approved by Food and Drug Administration (FDA) for the enrollee's diagnosis. The reviewer found that the use of onabotulinumtoxina for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use of onabotulinumtoxina is not medically reasonable or 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 onabotulinumtoxina have not been met. Specifically, the file does not show that the requested drug is approved by the FDA for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prochlorperazine tablets (J8597).  You asked the Plan to pre-approve the Prochlorperazine tablets. The Plan denied your request. The Plan says that Prochlorperazine is a benefit exclusion. The Plan also says that 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. Some oral anti-emetic drugs may be covered under Medicare Part B when specific criteria are met. In this case, the documentation does not support that the requested drug will be initiated within 2 hours of the administration of the chemotherapy or that the requested drug will be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine tablets (J8597).   Benefits for the Prochlorperazine 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient visit provided on September 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an outpatient visit. You say that you thought the proper steps were done to obtain authorization for the enrollee. The Plan denied your request. The Plan says there was no authorization from a primary care provider for the non-participating provider to render services.  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 an outpatient visit provided on September 27, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. You have morbid obesity, obstructive sleep apnea syndrome (OSAS)/ Obesity hypoventilation syndrome (OHS), congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).     The history of COPD is not well developed as it is not consistently mentioned in the record and Pulmonary function tests (PFTs) are not provided. Hypercapnea is noted by arterial blood gases (ABG), but no additional data is provided. You have been admitted recently though it appears that this was related to coronaviruse and CHF with non-compliance. You have utilized as Continuous positive airway pressure (CPAP) device sparingly for OSAS, though details are very limited, and a polysomnography (PSG) is not provided. There is no documentation to suggest a BiPAP with back up rate and AVAPS was utilized. You do not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Imaging
Decision: Favorable

 We decided that the Plan has to waive the deductible for advanced radiological diagnostic and laboratory services provided on December 14, 2018.  You asked the Plan to waive the deductible for advanced radiological diagnostic and laboratory services. You say that your deductible had been met at the time of service. The Plan denied your request. The Plan says that the correct cost-sharing was applied.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the case record does not include a breakdown of medical charges in 2018 to verify the Plan's assertion that your deductible had not been met on the date of service at issue. It is the Plan's responsibility to support their denial rationale. Since the Plan has not done so in this case, we must find in your favor. Therefore, we decided that the Plan has to waive the deductible for advanced radiological diagnostic and laboratory services provided on December 14, 2018.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient mental health psychotherapy visit (90833, 99214) provided on June 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an outpatient mental health psychotherapy visit. You say that it was impossible to obtain authorization due to the patient misleading you with the incorrect insurance information. You also say that the provider is not responsibility to request authorization for a Medicare patient to whom he renders services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services were not urgent or emergent, nor were they approved in advance.  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 an outpatient mental health psychotherapy visit (90833, 99214) provided on June 16, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient psychiatric care provided from August 24, 2021, to August 27, 2021.    You asked the Plan to pay for the inpatient psychiatric care. You say that the enrollee's attending psychiatrist felt that they would decompensate at a lower level of care if discharged prior to August 27, 2021. The Plan denied your request. The Plan says the request is not medically necessary because the records received show that the enrollee's condition has improved, and they are no longer a threat to themself or others.  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 pay for the inpatient psychiatric care. Our reviewer says that this enrollee did not require inpatient mental health treatment. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Our reviewer found that it did not appear that active treatment was taking place or that the services were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. The record does not include an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Our physician reviewer also found that the health plan's denial of continued inpatient psychiatric services appears appropriate.  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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric care provided from August 24, 2021, to August 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the revision of total knee arthroplasty (27486) provided on March 19, 2021.  You asked the Plan to pay for the revision of total knee arthroplasty. You say that this procedure was coded correctly. The Plan denied your request. The Plan says the billed code is not supported by the medical records submitted.  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 27486 is revision of total knee arthroplasty, with or without allograft; 1 component.  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 revision of total knee arthroplasty. Our reviewer says that the documentation does not support this claim as billed.  Our reviewer found the medical records provided does not include documentation to validate that a revision of total knee arthroplasty, with or without allograft; 1 component was performed on March 19, 2021. Therefore, this procedure cannot be verified.  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 revision of total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for the revision of total knee arthroplasty (27486) provided on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on August 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that payment should be processed for services rendered. The Plan denied your request. The Plan says no prior authorization for the date of service was obtained. The referring provider and the provider rendering services are both non-participating providers.  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 laboratory services provided on August 2, 2021, by an out-of-network (OON) provider.