Persius/hicric huggingface dataset:
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 the clinical information provided supports the need for a portable ventilator. The Plan denied your request. The Plan says a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP).  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 the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary. The enrollee has severe chronic obstructive pulmonary disease, recent coronavirus pneumonia, and other co-morbidities. An arterial blood gas while acutely ill showed a normal partial pressure of carbon dioxide (PaCO2), indicating the enrollee does not have chronic hypercarbic respiratory failure. The enrollee does not meet criteria for positive pressure ventilatory support during sleep.  Medicare does not cover a ventilator when used as BiPAP.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided by an out-of-network provider on December 3, 2020.  You asked the Plan to pay for the removal of residual tooth roots. You say that you do not agree with this denial. The Plan denied your request. The Plan says the rendered dental services are not covered benefits.  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 removal of residual tooth roots (D7250) provided by an out-of-network provider on December 3, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided on November 5, 2020, and November 24, 2020.  You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on November 2, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on November 5, 2020, and November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) provided on September 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says prior authorization was not received for these services rendered by an OON provider.  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 hospital outpatient clinic visit (G0463) provided on September 16, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received on April 20, 2021, April 22, 2021, and April 26, 2021.  You asked the Plan to waive the copayments for the PT services. You say that these services should be covered in full. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 copayment per visit for PT services.   You have been asked to pay a $40 copayment per visit for the PT services. You had three visits, so you were charged a total copayment of $120. 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 copayments for physical therapy (PT) services you received on April 20, 2021, April 22, 2021, and April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the CardioMEMS device.  You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the device is experimental/investigational for the enrollee's condition.  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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this patient's clinical management.  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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reduce the cost share for test strips.  You asked the Plan to reduce the cost share for test strips. You say that you do not have the money to pay for it. The Plan denied your request. The Plan says tier exceptions are not available.  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 durable medical equipment and related supplies.   We looked at the file and the rules. There is a 20% coinsurance for test strips. The test strips fall within the durable medical equipment and related supplies benefit category. 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 reduce the cost share for test strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits (97140).  You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. You have been instructed in a home exercise program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits (97140).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan has to pay for ambulance services (A0428 and A0425) provided on May 5, 2021.  You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because payment for this ambulance service is not included in the payment to the facility. The Plan denied your request. The Plan says that payment for this service is included in the base payment to the Skilled Nursing Facility.  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 the member was in a Part A covered Skilled Nursing Facility stay. Without this evidence we are unable to verify if payment for the ambulance services is included in the payment to the Skilled Nursing Facility. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated. Therefore, we decided that the Plan has to pay for ambulance services (A0428 and A0425) provided on May 5, 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 Ingrezza.  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 Ingrezza.      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 discharge day management services (99238) provided September 23, 2021  You asked the Plan to pay for the discharge day management. You say that CPT code 99238 was billed correctly as your provider pronounced death of patient. Please review the attachments and reprocess this claim for additional payment. The Plan denied your request. The Plan says this procedure has been billed and allowed the maximum number of times allowed.  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 99238 is hospital discharge day management, 30 minutes or less.  We find that CPT code 99238 is not supported in the medical record. Specifically, another discharge day management code, 99238, for the same date of service has been processed and paid. Only one hospital discharge day management service is payable per patient per hospital stay. Based on this information, we decided that Medicare rules for coverage of the discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the discharge day management services (99238) provided September 23, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast mammography services (77061) provided on August 6, 2021.  You asked the Plan to pay for the breast mammography services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this is an invalid procedure code for the services rendered.  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 77061 is diagnostic digital breast tomosynthesis; unilateral.  We looked at the file and Medicare rules. In this case, CPT code 77061 has a Status Code of "I" under the Physician Fee Schedule. This Status Code indicates that the billed code is not valid for Medicare purposes as Medicare uses another code for reporting of, and payment for, these services.    Based on this information, we decided that Medicare rules for coverage of the breast mammography services have not been met. Therefore, we decided that the Plan does not have to pay for the breast mammography services (77061) provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), provided on September 2, 2021.  You asked the Plan to pre-approve the comprehensive oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you have exceeded the Plan's maximum frequency allowance for this service.  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 pre-approve the comprehensive oral evaluation (D0150), provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional days for inpatient psychiatric admission.  You asked the Plan to pre-approve additional inpatient psychiatric admission. You say that the requested additional inpatient psychiatric admission is medically necessary. The Plan denied your request. The Plan says the requested additional inpatient psychiatric admission does not meet criteria.  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 additional inpatient psychiatric admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve additional days for inpatient psychiatric admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar epidural injections.  You asked the Plan to pre-approve lumbar epidural injections. You say that physical therapy is contraindicated, and the enrollee's lumbar radiculopathy is failing to improve with prescription anti-inflammatories. You say that the enrollee's activities of daily living and functional capacity is limited. The Plan denied your request. The Plan says the requested procedure exceeds the allowed limit of no more than four injection sessions in the last twelve months.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered for certain clinical indications and when specific criteria have been met.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar epidural injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records do not document that the enrollee has obtained at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using the same scale for at least three months. The records document pain relief from the lumbar epidural injections of only about 1-3 weeks in office visit notes of April 14, 2021, and October 15, 2021.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing services provided on October 26, 2020.  You asked the Plan to pay for the testing services. You say that samples are sent from the provider for the enrollee. The Plan denied your request. The Plan says the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided lists a place of service as an office setting. The records indicate the enrollee was at a skilled nursing facility at the time the specimen was obtained. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 25, 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 the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an assisted living facility setting and should have been billed with POS code 13. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 25, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Opdivo for the enrollee.  You asked the Plan to pre-approve Opdivo. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that Opdivoe is not being prescribed for a medically accepted indication.  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 Opdivo. Our reviewer says that Opdivo is medically reasonable and necessary. Our physician reviewer found that the enrollee's condition meets Medicare criteria for Opdivo. Opdivo is FDA-approved for the enrollee's diagnosis. Treatment of unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma after prior fluoropyrimidine- and platinum-based chemotherapy is FDA-approved.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve Opdivo for the enrollee.   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.