Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac rehabilitation (CR) program.
You asked the Plan to pre-approve the CR program. You say that you feel that this CR program is necessary to manage your condition. The Plan denied your request. The Plan says you do not have a condition for which this service can be covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab programs. The services must be provided in a doctor's office or an outpatient hospital setting.
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 CR program. Our reviewer says that the documentation does not show that the enrollee has a condition for which CR treatment is covered. Our physician reviewer found the enrollee is a 33-year-old female with diagnosis of postural orthostatic hypotension and sinus tachycardia. Echocardiogram has shown no structural heart disease with no documented arrhythmia. The enrollee has some symptoms of Postural orthostatic tachycardia syndrome (POTS) but no evidence of structural heart disease (valve, heart failure, prior transplant), ischemic heart disease (myocardial infarction, angina, prior revascularization) or any documented cardiac rhythm disturbances. Exercise training has been suggested as a possible therapy for orthostatic type symptoms, but with limited data for effectiveness. The enrollee does not have one of the Medicare-covered indication for a CR program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CR program have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac rehabilitation (CR) program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deluxe contour limited recline high back with solid seat pan, and a height adjustable foot platform bracket (CPT code K0108).
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the DME is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the DME. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a deluxe contour limited recline high back with solid seat pan, and a height adjustable foot platform bracket (CPT code K0108) is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
The requested items appear to be convenience items and exceed your medical need therefore they are 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve deluxe contour limited recline high back with solid seat pan, and a height adjustable foot platform bracket (CPT code K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says a lower level of care might be appropriate.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for carotid endarterectomy in April 2021. You were later treated for pneumonia and pulmonary cocciodiomycosis and are currently living at home with weakness despite home health physical therapy. Medical problems are
stable. There are no complex nursing or rehabilitation needs. You do 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 you 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).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care from June 17, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services on a daily basis. The Plan states while you may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy or skilled nursing services on an inpatient basis.
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 daily skilled services are not necessary. Our physician reviewer found at the time of admission, you required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of June 16, 2021, you did not require any skilled nursing or rehab services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of June 16, 2021. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved, however your function had plateaued by June 16, 2021, and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of June 16, 2021, you required custodial services. The denial for further inpatient skilled care is upheld. 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 continuation of skilled nursing facility (SNF) care from June 17, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services provided to the enrollee on August 18, 2020, by an out-of-network provider.
You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 office services provided to the enrollee on August 18, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for drug tests. You say that you are appealing with supporting documents. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network 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 drug testing provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 3
hours of intense rehab a day or medical supervision by a rehab physician 3 times a week.
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 physician reviewer found
that you were admitted to the acute care hospital for low back pain. Your medical conditions are stable. There
are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or
occupational therapy, in an intensive rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 29999 is not supported.
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 29999 is unlisted procedure, arthroscopy. We find that CPT code 29999 is not supported in the medical record. Specifically, the operative report does not contain documentation of an unlisted arthroscopic procedure. 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 pay for the surgical services rendered on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Jazzy Air 2 power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says this is being requested with a non-covered code.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found this power
wheelchair, which has an elevating seat, is not medically necessary. The documentation does not reveal
extenuating factors that would require the use of the specific wheelchair as it has an elevating seat which does
not serve a purely medical need and exceeds the enrollee's medical 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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Jazzy Air 2 power wheelchair for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a nasal surgery and a laryngoscopy performed on September 10, 2020, by an out of network provider.
You asked the Plan to pay for a nasal surgery and a laryngoscopy. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 a nasal surgery and a laryngoscopy performed on September 10, 2020, by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parathyroid imaging.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has an ionized calcium of
5.7 and a normal parathyroid hormone level and is asymptomatic. There is no evidence the calcium level was
rechecked. An ultrasound report was noted to be insufficient quality, but no report is provided. The records
indicate that surgery is contemplated but no surgical evaluation is present. The records do not support that the
requested parathyroid imaging 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve parathyroid imaging.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.

You asked the Plan to pre-approve 8 additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 8 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition.

Our physician reviewer found based on the medical records provided there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. The available records do not provide detail as to what skilled modalities (beyond the twelve approved treatments) are needed for treatment of your condition. Further utilization of the home exercise program appears appropriate at this point. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses (V2781, V2020, V2799) purchased on December 28,
2020.

You asked the Plan to pay for the eyeglasses. You say that you feel there has been a mistake, as these are
regular glasses to correct your vision. You are requesting reimbursement of the full $50 allowance for routine
eyewear. You think that perhaps a diagnostic code was provided with this claim in error. The Plan denied your
request. The Plan says that they contacted the provider and confirmed that you have a diagnosis relating to
cataracts. The copayment for Medicare-covered eyewear purchased post-cataract surgery from an out-ofnetwork
provider was applied correctly.

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 will provide reimbursement of up to $50 per calendar year for routine eyewear purchased
in-network or out-of-network.

We looked at the file and the Plan's rules. The Plan applied the cost-sharing amount for the Medicare-covered eyewear provided post-cataract surgery on the basis that this claim was submitted with a cataract-related diagnosis. The Plan reached out to the provider but was unable to confirm when or if you ever had cataract surgery. A diagnosis involving cataracts does not necessarily indicate that these glasses were purchased following cataract surgery. Because we cannot confirm when, if ever, this surgery took place, the assumption should be made that these glasses were purchased for routine vision correction. There is also no evidence that you had already used and exhausted this allowance in the 2020 calendar year. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have been met. Therefore, we decided that the Plan has to pay the full $50 routine eyewear allowance for the eyeglasses (V2781, V2020, V2799) purchased on December 28, 2020.

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.
You asked the Plan to pre-approve IRF care. You say that an IRF is necessary for this enrollee, he has had multiple recent hospital admissions and requires intensive physical and occupational therapy and medical oversight. The Plan denied your request. The Plan says an IRF is not medically necessary, a lower level of care such as a skilled nursing facility could be more appropriate for the enrollee.
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.