Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the deluxe frames, anti-reflective coating,
and polycarbonate lenses provided with post-cataract surgery eyewear.

You asked the Plan to provide reimbursement for the upgraded features. You say that you feel that you should
be reimbursed for the additional features you added to your eyewear. The Plan denied your request. The Plan
says payment has been made for the standard frames and lenses in this case. The additional upgrades are not
covered and cannot be reimbursed.

The Plan must follow Medicare rules. Medicare rules say that anti-reflective coating and polycarbonate lenses
are only covered in limited circumstances. Deluxe frames are noncovered.

In this case, there is no evidence that your physician documented the medical necessity of anti-reflective
coating, nor that you have functional vision in only one eye. Therefore, we decided that the Plan does not have
to provide reimbursement for the deluxe frames, anti-reflective coating, and polycarbonate lenses provided
with post-cataract surgery eyewear.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis.

You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the requested CT scan of the abdomen and pelvis is medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the abdomen and pelvis is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT scan of the abdomen and pelvis. Our reviewer says that the requested CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer found this enrollee with known metastatic non-small cell lung cancer was admitted in February 2021 with shortness of breath, fatigue, weakness and change in mental status and a CT of the chest showed progression of disease. She was also noted to have new onset adrenal insufficiency. A cat scan of the abdomen/pelvis is requested for further staging given these findings as this is new since the last CT of the abdomen and pelvis on 1/21/21. The service is 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 a CT scan of the abdomen and pelvis have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for left hip replacement. The enrollee's 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 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).

You asked the Plan to pre-approve the crown. You say that you would like this service to be covered. The Plan
denied your request. The Plan says this service is not covered under your benefit 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 pre-approve a
crown (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit and observation (99284, G0378) February 10, 2020, to February 11, 2020.
You asked the Plan to waive the copayment for the emergency department visit and observation. You say that the copayment is too high. 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 a $350 copayment per stay for outpatient observation stays. You have been asked to pay a $350 copayment for the emergency department visit and observation. This service falls within the Outpatient Hospital Observation 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 emergency department visit and observation (99284, G0378) February 10, 2020, to February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 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 was admitted for right sided weakness and a stroke. His 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 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. Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from March 25, 2019, to March 28, 2019 billed with secondary diagnosis code J96.21.
You asked the Plan to pay for the inpatient hospital care. You say that it is felt that this claim was correctly coded with the proper DRG assigned. The Plan denied your request. The Plan says the diagnostic testing in the record do not confirm that the enrollee had acute respiratory failure to a higher degree than their baseline.
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 reported diagnosis and procedure codes. In this case, you billed the services provided with secondary diagnosis code J96.21, Acute and chronic respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that the documentation does not support the reported secondary diagnosis code of J96.21. Our physician reviewer found that although acute respiratory failure was documented, there was insufficient clinical evidence in the records available for review to substantiate the coding of this condition. The diagnosis code(s) J96.21 has been revised to code J96.10 (Chronic respiratory failure, unspecified if with hypoxia or hypercapnia) as a secondary diagnosis. The review has determined that the documentation does not support including J96.21 (Acute and chronic respiratory failure with hypoxia) as a secondary diagnosis for this admission. The Plan's proposed change to reporting J96.10 (Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia) is correct. 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 the inpatient hospital care provided from March 25, 2019, to March 28, 2019 billed with secondary diagnosis code J96.21.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI upper extremity, any joint; without contrast
material(s) to be provided by the out-of-network provider.

You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says that there are no gap
issues and in-network providers are available to provide the service.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the MRI. We found no exception that would require the Plan to pre-approve the
MRI at issue. Therefore, we decided that the Plan does not have to pre-approve an MRI upper extremity, any
joint; without contrast material(s) to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for prosthetics.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says medically necessary care is available in network
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral out-of-network for prosthetics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that a SNF 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 SNF
admission.
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
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that there is no
documentation provided that indicates the patient requires skilled nursing services with the specialized skill,
knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary
and reasonable treatment. The patient does require daily skilled therapy services. However, this patient does
not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued services in the
acute inpatient rehabilitation facility is appropriate until the patient is stable to transfer to a lower level of care
such as a long term care facility, an assisted living facility, or home with home health 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 inpatient skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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 based on the documentation provided, the health plan's denial of LTACH coverage
should be upheld. The enrollee is currently undergoing treatment at an ACH for sepsis with respiratory failure,
in the setting of baseline COPD and pulmonary hypertension. The enrollee was intubated/ventilated and
subsequently received a tracheotomy. The enrollee is tolerating ventilator weaning. There is no evidence that
the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide
the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can
remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing LTC needs.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you need a therapeutic continuous glucose monitor. The Plan denied your request. The Plan says criteria is not met for a therapeutic continuous glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an external electrocardiographic recording provided on October 30, 2020
.
You asked the Plan to pay for the external electrocardiographic recording. The Plan denied your request. The Plan says that you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You or your PCP must obtain authorization from the plan prior to seeking 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 and the referring provider in this case are not network providers with the Plan. The Plan did not pre-approve the external electrocardiographic recording. 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 an external electrocardiographic recording provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 18, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says generally the enrollee must receive from a network provider. In most cases, care received from a non-network provider will not be 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 did not pre-approve the physician's services. 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 physician's services provided on April 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis and suspension sleeve (L1833, L2397).

You asked the Plan to pay for knee orthosis and suspension sleeve. You say that the items were medically necessary and reasonable. The Plan denied your request. The Plan says the prescribing physician did not discuss items with enrollee.

The Plan follows Medicare rules. Medicare rules say that for the requested orthoses to be covered you must meet the Medicare criteria listed in the 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 pay for knee orthosis and suspension sleeve. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient documentation of a credible evaluation with credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis and suspension sleeve (L1833, L2397).