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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has 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 enrollee does require physical therapy and occupational therapy services but
based on the medical records provided the enrollee does not require an intensive inpatient 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: 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 in pain, and unable to move around the house. The Plan denied your request. The Plan says this item is not covered by Medicare for your condition. 
 
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.   
 
The records do not show that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthosis from an out of network provider.
You asked the Plan to pre-approve an orthosis from an out of network provider. You say that this orthosis is
medically necessary. The Plan denied your request. The Plan says the requested provider is out of network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan durable medical equipment, such as an orthosis, requires prior authorization and must be obtained in
network. The requested provider is not in network. We found no exception that would require the Plan to preapprove
this orthosis out of network. Therefore, we decided that the Plan does not have to pre-approve out of
network orthosis equipment.
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 inpatient level care is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tumor Treatment Field Therapy device (E0766).
You asked the Plan to pre-approve the Tumor Treatment Field Therapy device. You say that the Tumor Treatment Field Therapy is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that TTFT is not covered for recurrent tumors. We looked at the file and Medicare rules. The record shows the enrollee has a recurrent tumor. Based on this information, we decided that Medicare rules for coverage of the Tumor Treatment Field Therapy device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Tumor Treatment Field Therapy device (E0766).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you will be seriously injured if you fall. The Plan denied your request. The Plan says the admission 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 above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you had a fall onto your left hip. You received oral medications and had stable vital signs. You received home physical therapy and need assistance with walking 75 feet with a cane. You have no skilled nursing or skilled therapy needs. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152) provided on December 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older". 
 
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 services. Our reviewer says that the use of CPT code 99152 is not supported by the records provided. Our physician reviewer found that the documentation does not include an independent trained observer was present during procedure to monitor patient's level of consciousness and physiological status. 
 
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 pay for the services (CPT 99152) provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 pre-approve ondansetron tablets.
Benefits for 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health treatment. 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. 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 inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of June 25, 2020 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats to the safety of yourself or others. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on January 1, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient records to determine whether payment is due. 
 
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 testing. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found the documentation is insufficient to demonstrate that the nasal swab testing was medically reasonable and necessary for the enrollee in this case. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on January 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 a diagnosis of
unilateral primary osteoarthritis of the right knee. He has not tried and failed the Plan's required drugs of
Orthovisc and Monovisc. The records do not support that the required drugs would be less effective or
contraindicated; therefore, Synvisc is not reasonable or medically necessary at this time.
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 Synvisc.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 17, 2019 through December 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found this patient meets criteria for admission with pneumonia, injuries, and electrolyte abnormalities especially given comorbid conditions. It was certainly reasonable to admit this patient to the hospital and there was a reasonable chance that two (2) or more midnights would be necessary for the hospital stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 17, 2019 through December 20, 2019.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 16, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that you would like reconsideration because you
were told this provider is in-network with the Plan. The Plan denied your request. The Plan says this provider is
out-of-network and there is no authorization on file for the services provided.
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 has network providers
available who can provide 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 March 16, 2020
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided to the enrollee from November 26, 2019 to December 6, 2019 as a new admission. 
 
You asked the Plan to pay for these services as a new admission. You say that this admission was separate and distinct from the previous admission that occurred from November 20, 2019 to November 22, 2019 and should be paid by the Plan as a separate admission. The Plan denied your request. The Plan says that the enrollee was admitted for the same issues as the previous admission. 
 
The Plan must follow Medicare rules. The rules say that readmissions can be considered part of or a continuation of the first admission depending on the circumstances for the return admission. We asked our physician review to look at the case file and the Medicare rules. Our Physician reviewer says that the readmission was medically necessary. The enrollee was having diarrhea unresolved with the prescribed antibiotics and additional testing including culture with IV fluids and monitoring was warranted until a more effective treatment was provided. The records do not show that the previous admission was premature.  The enrollee exhibited a positive response from the Vancomycin for the diarrhea and was appropriately discharged home with continued antibiotic treatment. It appears a new infection (possibly a URI) had aggravated the diarrhea or the effect of the ertapenem worsened the diarrhea which was unexpected and required a re-evaluation.  
 
We looked at this physician's review, the case file and the Medicare rules. Based on this information we found Medicare criteria for payment of this service as a new admission were met. Therefore, we decided that the Plan has to pay for inpatient care provided to the enrollee from November 26, 2019 to December 6, 2019 as a new admission.  
 
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 waive the copayment for inpatient hospital care from October 19, 2019 through October 22, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on October 19, 2019 and discharged on October 22, 2019. You were asked to pay a $515 copayment per day from October 19, 2019 through October 21, 2019, days 1-3 of your inpatient hospital care. You were discharged on October 22, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $515 copayment per day required for days 1-3. 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 inpatient hospital care from October 19, 2019 through October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for premier level hearing aids purchased on May 21, 2019. 
 
You asked the Plan to pay for premier level hearing aids. You say that you were advised that you would be reimbursed the difference between the highest covered hearing aid in 2019. The Plan denied your request. The Plan says these hearing aids are not listed in your EOC as covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of premier level hearing aids have not been met. These premier level hearing aids were not a covered benefit in 2019. Your EOC states, coverage for hearing aids is limited to the supplemental hearing aid vendor. Up to two (2) aids per year, one (1) aid per ear, $250 copay for standard level hearing aid, $475 copay for superior level hearing aid, $650 copay for advanced level hearing aid, $850 copay for advanced plus level hearing aid. Therefore, we decided that the Plan does not have to pay for premier level hearing aids purchased on May 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift.
You asked the Plan to pay for a stair lift. You say that you are requesting reimbursement from the Plan for a stair lift that you had purchased. You stated that you discussed the need of the stair lift with your family doctor and you reviewed coverage documentation that you say did not indicate that the lift would not be covered. You asked the Plan to reconsider their denial and provide some payment for the stair lift. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 pay for a stair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4550, 99156, 99157) provided on December 3, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure codes 99156 and 99157 are each part of an edit pair with procedure code 62284. Procedure code 66284 is a column one code, and procedure codes 99156 and 99157 are column two codes. Procedure code 62284 has been for this date of service, which means that procedure codes 99156 and 99157 are not eligible for payment. 
 
Medicare rules also say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. Code A4550 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for A4550. Therefore, we decided that the Plan does not have to pay for the services (A4550, 99156, 99157) provided on December 3, 2019.