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

We decided that the Plan has to pay for hospital discharge day management (99239) provided on April 12, 2021.
You asked the Plan to pay for hospital discharge day management. You say that this service was billed appropriately and should be paid. The Plan denied your request. The Plan says that only one hospital discharge day management service is payable per patient per hospital stay. Only the attending physician of record reports the discharge day management service. This service was billed improperly and remains denied.
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 Plan has not forwarded any evidence that another Hospital Discharge Day Management code has been billed or paid. Additionally, the record does not include any evidence that the billing provider was not the attending physician on this date of service. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for hospital discharge day management (99239) provided on April 12, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Veltassa.
You asked the Plan to pre-approve Veltassa. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Veltassa.
Benefits for Veltassa 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided on August 20, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the pharmacogenomic test. You say that the test was medically necessary, and it should be paid at the established rate. The Plan denied your request. The Plan says the service was provided OON without prior authorization, and therefore is not covered.

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 the unlisted molecular pathology procedure (81479) provided on August 20, 2020, 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 powered pressure-reducing air mattress (E0277) for the enrollee.
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of multiple pressure wounds.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mattress. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is documentation that the enrollee has a single stage II pressure ulcer of the coccyx but there is no documentation that the enrollee has either multiple stage II pressure ulcers located on the trunk or pelvis, which have been treated in a comprehensive program, large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
You asked the Plan to pre-approve 7 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 7 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The provided records do not document a change in condition, unstable medical illness, wound, recent hospitalization or medication change or other need for a skilled nursing service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health skilled nursing visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 16, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on April 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the basic metabolic panel (80048),
radiologic examination, chest; 2 views (71046) and electrocardiogram (ECG), routine ECG with at least 12
leads; tracing only, without interpretation and report (93005) provided March 30 2021, and the colonoscopy,
flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (45378) and
hemorrhoidectomy, internal, by rubber band ligation (46221) provided April 14, 2021,
You asked the Plan to waive the copayment for basic metabolic panel, chest x-ray, ECG tracing, diagnostic
colonoscopy and hemorrhoidectomy. You say that your colonoscopy was routine, and you should not be
charged a copayment for it. The Plan denied your request. The Plan says the copayments were 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 $35
copayment for Medicare-covered lab services, a $100 copayment for Medicare-covered X-ray services and
Medicare-covered diagnostic procedures/tests, a $40 copayment for each Medicare-covered specialist visit and
a $350 copayment for each Medicare-covered outpatient surgical service.
You have been asked to pay a total of $598.10 for the basic metabolic panel, chest x-ray, ECG tracing,
diagnostic colonoscopy and hemorrhoidectomy. While the Plan covers screening colonoscopies with a $0
copayment, the records show that this colonoscopy with hemorrhoidectomy was medical in nature. The basic
metabolic panel, chest x-ray, ECG and medical colonoscopy with hemorrhoidectomy fall within the Outpatient
hospital services benefit category. The specialist visit associated with the colonoscopy falls within the
Physician/Practitioner services, including doctor's office visits 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 basic metabolic panel (80048), radiologic examination, chest; 2 views (71046)
and electrocardiogram (ECG), routine ECG with at least 12 leads; tracing only, without interpretation and
report (93005) provided March 30 2021, and the colonoscopy, flexible; diagnostic, including collection of
specimen(s) by brushing or washing, when performed (45378) and hemorrhoidectomy, internal, by rubber band
ligation (46221) provided April 14, 2021,
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 does not meet
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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided on January 14, 2021 by an
OON provider.

You asked the Plan to pay for the echocardiography. You say that you are not always informed that the enrollee
has a primary insurance which requires pre-approval prior to the services being rendered. The Plan denied your
request. The Plan says this service was rendered by a non-participating provider. The Plan also says that the
enrollee was referred by another non-participating provider, and prior authorization was not 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.
Therefore, we decided that the Plan does not have to pay for the echocardiography provided on January 14,
2021 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting
review of denial of services. The Plan denied your request. The Plan says you exhausted your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
Review of the file shows that you exhausted your benefit limit. Your 2021 EOC states, up to twenty-four (24)
one-way trips are covered per calendar year (limited to ground transportation only).
Therefore, the 25th trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not have
to pre-approve ten (10) additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compression stockings.

You asked the Plan to pre-approve the compression stockings. You say that you suffer from pain and these compression stockings would be helpful. The Plan denied your request. The Plan says the coverage criteria for compression stockings have not been met.

The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the compression stockings.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fusion of spine bones with removal of disc at lower spinal column, anterior approach (CPT code(s): 22840, 22853, 22558, and 22612).

You asked the Plan to pre-approve the services. You say that you have been waiting for this surgery for over a month and you are currently in a lot of pain, you cannot bend, and you were recently hospitalized because of your condition. The Plan denied your request. The Plan says the notes sent to the Plan by your doctor do not have enough information to show you meet the standards for this surgery.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for fusion are not met. There is no documented spinal instability, or fracture. Fusion for lumbar DDD with back pain has uncertain results.

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 fusion of spine bones with removal of disc at lower spinal column, anterior approach (CPT code(s): 22840, 22853, 22558, and 22612).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Yervoy.
You asked the Plan to pre-approve the requested drugs. You say that the enrollee will respond on the second-choice immunotherapy. The Plan denied your request. The Plan says the effectiveness of the drugs in the setting of disease progression on Keytruda have not been demonstrated.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drugs. Our physician reviewer found that the enrollee has metastatic non-small cell lung cancer. The records show that the enrollee progressed on Keytruda, another PD-1 inhibiter. The documentation does not support 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 the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Yervoy.
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 stay is medically necessary. The Plan
denied your request. The Plan says the stay 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 the enrollee was admitted with sepsis due to aspiration pneumonia and diverticulitis.
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 she is not currently receiving but that would be available at
the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 you are a 79-year-old female with a past medical history of hypertension and chronic obstructive pulmonary disease who has been in an acute inpatient rehabilitation facility since September 14, 2021, after treatment in an acute hospital for a stroke. Based on the medical records provided, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until the patient is stable to transfer to a lower level of care such as home with home health care or to a nursing facility with part-time 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on March 6,
2019 to November 25, 2019 by an out-of-network (OON) provider.
You asked the Plan to pay for the DME provided by an OON provider. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 the durable medical equipment (DME) provided
on March 6, 2019 to November 25, 2019 by an out-of-network (OON) provider.