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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 that the enrollee was admitted to the current acute care hospital with chest pain 
diagnosed as a myocardial infarction. He was taken to a cath lab but this was complicated by being diagnosed 
with type b dissection requiring emergent repair. He developed lactic acidosis and was found to have a necrotic 
small bowel which was resected. He later underwent cholecystectomy, jejunojejunostomy, and abdominal 
washout and was diagnosed with sepsis and a urinary tract infection causing encephalopathy and respiratory 
failure requiring intubation. He has since been able to be extubated and has started physical therapy, oxygen 
weaning, and a percutaneous endoscopic gastrostomy tube was placed. 
 
It appears that the patient is improving and may require only short term additional acute care services which 
can safely be administered at the current facility. The patient does not require any services at the LTACH that 
are not already available at the current facility. There are no services at the LTACH that the patient requires 
that are not already available and covered at the current facility. Therefore, this request for LTACH services 
will be considered not medically necessary at this time. Transfer to a lower level of care may be considered 
soon when treatment is completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for clinic services. You say that these services were appropriate and medically 
necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and 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 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 medical services provided on February 4, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 17, 2020. 
 
You asked the Plan to pay for an LSO. You say that the requested item is medically necessary. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, a 
purported proof of delivery was provided without a signature. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for an LSO (L0650) provided on September 17, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services received on August 26, 2020. 
 
You asked the Plan to pay for the services. You say that you should be reimbursed for these services. The Plan 
denied your request. The Plan says the plan does not cover services performed by a privately contracted 
provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services received on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve walk-in shower. You say that you are appealing with supporting documents. 
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because a walk-
in shower is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for wound care. We decided that the Plan does not have to waive the copayment for wound care provided on the additional dates of service.

You asked the Plan to waive the copayment for wound care. You say that this should have been billed as debridement, not an outpatient surgery. The Plan says that the correct copayments have been applied.

We decided that the Plan has to waive the copayment for wound care.

An Evidence of Benefits was not sent in to verify that services took place. Therefore, we decided that the Plan has to waive the copayment for wound care.

We also decided that the Plan does not have to waive the copayment for wound care provided on the additional dates of service.

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 wound care. The total amount you are being asked to pay is $2,250 ($250 x 9 visits = $2,250). Therefore, we decided that the Plan does not have to waive the copayment for wound care.

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 needle electromyography (95886), nerve conduction studies (95910), somatosensory testing (95938) and electroencephalogram (95955).
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed place of service (POS) 15 is not supported and the technical component of these services is not payable in a facility setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 95938, 95955, 95910 and 95886 are not supported in the record. Specifically, the record indicates that these services were rendered in a facility setting. This means that place of service code 15 is not appropriate for the services rendered. Additionally, payment for these services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies (95910), somatosensory testing (95938) and electroencephalogram (95955).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the immediate denture (D5140) provided
on June 4, 2020.
You asked the Plan to pay the in-network rate for the immediate denture. You say that you were under the
impression that your plan covered dental up to $1,000. You also say that you received a check for only $497.
The Plan denied your request. The Plan says immediate denture is not listed as a covered 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 pay the in-network
rate for the immediate denture (D5140) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (Hoveround). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says your mobility limitation can be sufficiently and safely resolved by the use of an 
appropriately-fitted cane or walker. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services are not medically reasonable or necessary. Our physician reviewer found you have a 
personal mobility deficit but the documentation does not reveal that it impairs participation in MRADLs. The 
documentation is not clear why the deficit is unable to be helped by a  walker, cane or manual wheelchair. You 
may be able to safely operate the PMD but the documentation does not support that it is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (Hoveround).
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 enrollee needs rehabilitation. You say that the enrollee cannot go to a nursing home or skilled nursing facility within a 30-mile radius of her home, and would need to go to a select skilled nursing facility for her condition. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for disorientation, lethargy and end stage renal disease. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: 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 above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. Finally, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need these trips to rehab. The Plan denied your request. The Plan says that your request exceeds the plan allowed benefit.
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. The Plan covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a Trilogy ventilator.

You asked the Plan to pre-approve Trilogy ventilator. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because there is no evidence that a ventilator is indicated for you and you may meet criteria for a bi-level positive airway pressure (BiPAP) instead.

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 Trilogy ventilator. Our reviewer says that you do not meet the Medicare criteria for the requested ventilator. Our physician reviewer found you do not have a diagnosis of chronic obstructive pulmonary disease (COPD), neuromuscular disease, or thoracic restrictive disease. The appropriate treatment for your condition is a continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). A ventilator is not medically necessary, and Medicare does not cover it for your diagnoses.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Trilogy ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a Trilogy ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy and infusion pump and supplies provided from April 1, 2020 to April 15, 2020.
You asked the Plan to pay for the chemotherapy and infusion pump and supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the chemotherapy and infusion pump and supplies was used in the outpatient hospital setting. Therefore, we decided that the Plan does not have to pay for the chemotherapy and infusion pump and supplies provided from April 1, 2020 to April 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from October 1,
2020, to October 14, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that you were sent to this facility for
physical therapy and not sub-acute nursing. The Plan denied your request. The Plan says the copayment
amount you are being charged is correct.
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 $0
copayment each day for days 1 to 20 per admission, and a $150 copayment each day for days 21 to 100 per
admission for Skilled Nursing Facility (SNF) care. This SNF stay lasted 21 days, resulting in a total copayment
amount of $150.
You have been asked to pay a $0 copayment each day for days 1 to 20 per admission, and a $150 copayment
each day for days 21 to 100 per admission for SNF care. SNF care falls within the Skilled Nursing Facility
(SNF) care 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 SNF care provided
from October 1, 2020, to October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D extra-oral projection x-ray (D0250).

You asked the Plan to pay for the 2D extra-oral projection x-ray. You say that this service was necessary. The Plan denied your request. The Plan says this service is not covered by the Plan.

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 2D extra-oral projection x-ray (D0250).