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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 surgical treatment of a hip fracture after a fall. 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 this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for subacute rehabilitation services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee was resubmitted to your facility on January 29, 2021. You say that the authorization for subacute rehab was denied. You say that you feel the enrollee would benefit from rehabilitation services. The Plan denied your request. The Plan says the Medicare guidelines have not been met. The Plan says that there is no apparent skilled daily medical or therapy needed. The Plan also says that the requested SNF care is not medically necessary.
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 the SNF services. Our reviewer says
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. Therefore, the reviewer found that admission to a SNF for inpatient skilled rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for subacute rehabilitation services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the fosfomycin, 3 gm packet, and the phenazopyridine, 200 mg tablet.

You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

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 pay for the fosfomycin, 3 gm packet, and the phenazopyridine, 200 mg tablet.

Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are experiencing an increased need for a wheelchair, due to the condition of your feet. You say that you need the requested foot orthotics prior to surgery so that they can be used immediately after your cast is removed. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 gastrointestinal bleeding. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear.

You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says you are responsible for the cost share.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $100 per calendar year.

We looked at the file and the Plan's rules. The records show that the Plan paid $100 toward the eyewear in question. You are responsible for any amount over the $100 benefit limit. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox. You say that you do not administer Xeomin and are requesting consideration of approval for Botox for this reason. The Plan denied your request. The Plan says that the enrollee has not tried the preferred drug, Xeomin.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract does not clearly indicate whether the Plan has implemented step therapy criteria applicable to Botox. We looked at your contract with the Plan. We did not see where the contract says that step therapy rules have been implemented for use of Botox. The Plan did not provide any other rationale to support a denial for the requested Botox. Therefore, we decided that the Plan has to pre-approve Botox (J0585).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 diagnostic radiology 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 diagnostic radiology services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller and related accessories (E2377, E2311, E2313), additional 3'' link (K0108) and custom back adapter plate (K0108).
You asked the Plan to pre-approve the expandable controller and related accessories, additional 3'' link, and custom back adapter plate. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered.
The Plan must follow Medicare rules. The rules say that an expandable controller must be medically necessary and reasonable. The rules also say that items coded K0108 as added components for a wheelchair is incorrect coding. 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 expandable controller. Our reviewer says that the expandable controller is not medically necessary and reasonable. Our physician reviewer found the patient's strength and function in the upper extremities with the ability to feed himself indicates that the patient can control any power options through their own individual switches. 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 expandable controller have not been met. In addition, the items coded K0108 appear to be ineligible for coverage as they are added components that are incorrectly coded according to Medicare rules Therefore, we decided that the Plan does not have to pre-approve the expandable controller and related accessories (E2377, E2311, E2313), additional 3'' link (K0108) and custom back adapter plate (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit, x-rays, and physical therapy services by a participating provider on June 23, 2020.

You asked the Plan to waive the copayment for a specialist office visit, x-rays, and physical therapy services. You say that this was a pre-operation admission testing, and you should not a copayment for this. The Plan denied your request. The Plan says the correct copayment has been 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 $40 copayment, a $15 copayment, a $40 copayment for physician/practitioner services/specialist, outpatient diagnostic tests/x-rays, outpatient rehabilitation services. 

You have been asked to pay a $40 copayment for a specialist office visit, a $15 copayment for x-rays, and a $35.07 copayment which is less than your copayment amount of $40 copayment for physical therapy services. The total amount you are being asked to pay is $90.07 ($40 + $15 + $35.07 = $90.07). A specialist office visit falls within the physician/practitioner services/specialist benefit category, x-rays fall within the outpatient diagnostic tests/x-rays benefit category, and physical therapy services falls within the outpatient rehabilitation services 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 a specialist office visit, x-rays, and physical therapy services by a participating provider on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out-of-network provider on October 8, 2020.
You asked the Plan to pay for physician services. You say that the enrollee was in a nursing facility, so the doctor was not responsible for getting authorization. You say that the claim should be processed for reimbursement. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 physician services provided by an out-of-network provider on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services only when they are provided by an in-network provider.

We looked at the file and the Plan's rules. The records show that the vision services were provided to you by an out-of-network provider. Out-of-network routine vision services are not covered. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided on
September 21, 2020.
You asked the Plan to waive the copayment for an electrocardiogram. You say that the service was done in
your primary care physician's office and you want the Plan to reconsider your copayment amount. 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 for
outpatient diagnostic tests.
You have been asked to pay $16.08 which is the allowed amount for an electrocardiogram. An
electrocardiogram falls within the outpatient diagnostic tests 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 an electrocardiogram (93000) provided on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic custom shoes (A5501) and diabetic custom inserts (A5513) provided on April 15, 2020.
You asked the Plan to pay for diabetic custom shoes and diabetic custom inserts. You say that the requested items are 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. 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 diabetic custom shoes (A5501) and diabetic custom inserts (A5513) provided on April 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a trunk flap (15734) provided on July 20, 2020.
You asked the Plan to pay for a trunk flap. You say that this code is supported. The Plan denied your request. The Plan says this is not documented in the records.
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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk. 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 a trunk flap. Our reviewer says that this code is not supported. Our physician reviewer found the operative report does not document a prepared flap from the donor area to the site needing repair, and closure of the donor site, meaning this service cannot be verified. 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 trunk flap have not been met. Therefore, we decided that the Plan does not have to pay for a trunk flap (15734) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the services. You say that the doctor cannot treat you without an office visit. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006).

You asked the Plan to pre-approve the heavy-duty manual wheelchair. You say that the wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that rules state that a manual wheelchair is covered when the member has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living.

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 heavy-duty manual wheelchair. Our reviewer says that the wheelchair is not medically necessary. Our physician reviewer found the available records do not clearly demonstrate a mobility limitation that significantly impairs the enrollee's ability to participate in one or more mobility-related activities of daily living.

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 heavy-duty manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair (K0006).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a home health aide.

You asked the Plan to reimburse you for the custodial care services. You say that you were told that you would be covered for custodial care during the time that you had broken both of your wrists. You also say that you have satisfied your deductible and coinsurance. The Plan denied your request. The Plan says a doctor must order the home health aide, and a Medicare-certified home health agency must provide it. The Plan says that there is no evidence of skilled services being provided. The Plan says that the provider is not a Medicare-enrolled provider. The Plan also says that the services are not covered.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care services have not been met. Therefore, we decided that the Plan does not have to reimburse you for a home health aide.