Persius/hicric huggingface dataset:
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 that the patient was admitted for hypertensive emergency and multifocal intracranial hemorrhages. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the portable oxygen concentrator. You say that the current oxygen system
only lasts an hour and has bulky tanks. The Plan denied your request. The Plan says Medicare does not pay for
duplicative equipment.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.

The file shows that you have home oxygen system. A home oxygen system serves the same purpose as the
portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable
oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on January 17, 2021, to January 20, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that this patient was appropriately admitted to an inpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on January 17, 2021, to January 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from November 2, 2020, to December 31, 2020.
You asked the Plan to pay for home health care. You say that you are appealing with supporting records and should be paid in full. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not enrolled in the Medicare program and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, a provider must be enrolled in the Medicare program. We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from November 2, 2020, to December 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on May 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the MRI 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 magnetic resonance imaging (MRI) provided on May 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320).

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 endodontic therapy (D3320).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the advanced life support, non-emergency ambulance services (A0426) provided April 17, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you request an appeal of the $250 charges for the ambulance rides. You receive a little over $1,100 and cannot pay for these ambulance bills. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these services. 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 advanced life support, non-emergency ambulance services (A0426) provided April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services (10060) provided May 6, 2021.

You asked the Plan to waive the copayment for the observation services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $175 copayment for outpatient services. 

You have been asked to pay the Medicare allowable amount of $172.98 for the observation services. The observation services fall within the outpatient services benefit category.

The allowable amount is less than the amount listed in the Evidence of Coverage. 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 observation services (10060) provided May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on November 2, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the portable x-ray services. You say that these services were provided due to medical necessity to prevent choking and aspiration risk. Because this enrollee requires special supervision and has difficulty being transported, this procedure is required onsite. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on November 2, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal care assistant (T1019).

You asked the Plan to pre-approve a personal care assistant. You say that this care is necessary for the
enrollee's condition. The Plan denied your request. The Plan says neither the Plan nor Medicare cover this
service.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a personal care assistant have not been met. Specifically, we find that the services at issue in this
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a
personal care assistant (T1019).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378).
You asked the Plan to pre-approve a diagnostic colonoscopy. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.
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 a diagnostic colonoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the available records do not support that the enrollee has iron deficiency nor a history of colon polyps. The enrollee does have a history of chronic anemia. Based on the provided medical documentation, the enrollee does not meet coverage criteria for colonoscopy for the indication of iron deficiency. 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 diagnostic colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve an implant (D6010), implant supported crown (D6066), and an abutment (D6057) for tooth # 13.

You asked the Plan to pre-approve the dental services. You say that the enrollee is only missing 1 tooth in the upper arch. You also say that the enrollee qualifies for an implant according to the insurance guideline and the space is enough to place an implant. The Plan denied your request. The Plan says that there is not adequate space to accommodate an anatomically correct tooth. The Plan also says that the services are not medically necessary.

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 dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the implant services are not medically necessary. Our physician reviewer found the provided documentation supports that there is adequate space to accommodate an anatomically correct tooth in space # 13. Therefore, the reviewer found that the implant services are medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Specifically, the record shows that there is adequate tooth space to accommodate an anatomically correct tooth. Therefore, we decided that the Plan has to pre-approve an implant (D6010), implant supported crown (D6066), and an abutment (D6057) for tooth # 13.

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 proton beam radiation treatment delivery and stereoscopic
x-ray guidance provided on February 12, 2021.

You asked the Plan to pay for proton beam radiation treatment delivery and stereoscopic x-ray guidance. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for proton beam radiation treatment delivery and stereoscopic x-ray guidance provided on February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating
provider on May 27, 2020, to May 30, 2020.

You asked the Plan to pay for inpatient hospital care. You say that you would like this claim reprocessed and
fully reimbursed. The Plan denied your request. The Plan says that the condition in question was not clinically
evaluated, did not receive therapeutic treatment, had diagnostic procedures, extended the length of hospital stay
or increased nursing care/monitoring.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with Secondary diagnosis code K50.90, Crohn's
disease unspecified without complications. 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
inpatient hospital care. Our reviewer says that while the provider documentation indicated the condition of
Crohn's disease, medical record documentation did not indicate that Crohn's disease met the definition of a
secondary diagnosis during this episode of care. In addition, the Abdomen/Pelvis computed tomography scan
result date is dated after the patient discharge date. The medical records do not support the billing of secondary
diagnosis code, K50.90 - Crohn's disease unspecified without complications. Our physician reviewer found
medical record documentation did not indicate that Crohn's disease met the UHDDS definition of a secondary
diagnosis during this episode of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided by a non-participating provider on May 27, 2020, to May 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.

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 the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic clear cell renal cell carcinoma. There is no documentation in the National Comprehensive Cancer Network (NCCN) guidelines or the Medicare-approved major drug compendia to support the use of Opdivo for this diagnosis. Records indicate the request is for monotherapy with Opdivo and the enrollee has not had prior anti-angiogenic therapy. The Opdivo is therefore not safe and effective or reasonable and medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (0398T).

You asked the Plan to pre-approve a magnetic resonance image guided high intensity focused ultrasound. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that magnetic resonance image guided high intensity focused ultrasound is medically necessary when the criteria listed in the Medicare Rules section of this letter are 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 a magnetic resonance image guided high intensity focused ultrasound. Our reviewer says that the service is not medically necessary. Our physician reviewer found no CRST score was provided and the member was noted to have been referred for a neurosurgical evaluation. It is unclear if such a consult took place and if so, if the surgeons indicated that he would not be a candidate for a DBS. 

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 magnetic resonance image guided high intensity focused ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (0398T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Guardant360 testing provided to the enrollee on February 4, 2021.

You asked the Plan to waive the coinsurance for the testing. You say that there is no in-network provider that can provide comparable testing. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for molecular and predisposed genetic testing. 

You have been asked to pay 20% coinsurance ($700) for the testing. The testing falls within the molecular and predisposed genetic testing 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 Guardant360 testing provided to the enrollee on February 4, 2021.