Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical and occupational therapy services in the home health setting beyond January 11, 2020.You asked the Plan to pre-approve the continued home health services. You say that the enrollee needs to continue to receive this care.The Plan denied your request. The Plan says the enrollee no longer requires skilled care in the home. Remaining needs are custodial in nature.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 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 continued home health services. Our reviewer says that the documentation does not show that ongoing home health care is necessary for this enrollee. Our physician reviewer found the request for continued skilled therapy services is not required to effectively provide treatment, care, and/or services which are medically necessary for the patient in order to maintain or perform a maintenance program. The patient has had extensive prior therapy and should be able to participate in an independent home exercise program. The documentation does not support that the patient requires the ongoing professional skills of a therapist to treat their illness or injury, improve their condition, maintain their condition, or prevent deterioration of their condition.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 continued home health services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued physical and occupational therapy services in the home health setting beyond January 11, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on April 3, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitutefor an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on April 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided on July 19, 2019 through July 24, 2019.You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration as these services were medically necessary. The Plandenied your request. The Plan says the hospital failed to seek preapproval for admission prior to providing post stabilization care. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approvalis required. 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 post stabilization care. Our reviewer says that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services after the emergency room evaluation. Our physician reviewer found there was no documentation provided necessitating post-stabilization care services at the non-Plan facility.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 post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization care provided on July 19, 2019 through July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you are suffering and cannot walk to the mail box. You say that you need the orthotics to live a normal life.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-approvefoot orthotics.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from October 31, 2019 to November 1, 2019.You asked the Plan to waive the copayment for the emergency room. You say that you were transferred to another room and told you were admitted. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for the emergency room. The emergency room falls within the "Emergency care" benefit category. The medical record shows that you were admitted to observation.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 room visit provided from October 31, 2019 to November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea stair glide.You asked the Plan to pre-approvea stair glide. You say that the stair lift is a necessity for the enrollee to resume living in her home. You stated that she cannot afford the requested stair lift on her own and her home is two stories, with her bedroom, bathroom and shower being located on the second floor. You say that due to her physical state, she requires a wheelchair and is unable to negotiate a set of stairs. You believe that the requested stair lift is required for the enrollee to resume her independent living.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 pre-approvea stair glide.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea panniculectomy (15830).You asked the Plan to pre-approvea panniculectomy (15830). You say that the requested panniculectomy is medically necessary.The Plan denied your request. The Plan says the requested panniculectomy 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 a panniculectomy (15830). Our reviewer says that the requested panniculectomy is not medically necessary. Our physician reviewer found the enrollee underwent gastric bypass surgery in September of 2018. Her peak weight was 445 lbs. On 12/26/19, it is documented that the enrollee's weight has been stable at 250 lbs for 6 months. The enrollee reported moisture and irritation around the umbilicus. The physical exam noted obesity, but there is no documentation of candidiasis, intertrigo or tissue necrosis.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 panniculectomy (15830) have not been met.Therefore, we decided that the Plan does not have to pre-approvea panniculectomy (15830).
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 physician reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies provided on September 17, 2018.
You asked the Plan to pay for the ambulance supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulance supplies are not payed separately.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. Ambulance supplies are included in the approved ambulance fee. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance supplies provided on September 17, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea PET scan for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthe CT scan in April of 2019 showed no evidence of recurrent disease.The Plan must follow Medicare rules. Medicare rules say that PET 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 the scan. Our reviewer says that the requested scan isnot medically reasonable or necessary. Our physician reviewer found CMS approves up to 3 PET/CT scans per diagnosis unless there are special circumstances such as equivocal clinical or imaging findings requiring PET/CT for clarification. This enrollee hasnot had any positive findings on prior PET scans, has no clinical evidence of recurrence and CT battery of exams in 2019 showed no evidence of tumor recurrence/metastases.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea PET scan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit provided on September 13, 2019.
You asked the Plan to reduce the copayment for the office visit. You say that you say this provider is in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $30 copayment for each out-of-network PCP visit. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network.
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 reduce the copayment for the office visit provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forobservation care (99226) and discharge day management (99217) provided from March 12, 2018 to March 13, 2018.You asked the Plan to pay forobservation care and discharge day management. You say that this claim was filed timely.The Plan denied your request. The Plan says this claim was filed more than a year after the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for observation care and discharge day management was not filed until August 14, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forobservation care (99226) anddischarge day management (99217) provided from March 12, 2018 to March 13, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One (J7325).You asked the Plan to pre-approveSynvisc-One. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been 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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One (J7325).
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria for IRF care 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 not meet criteria for IRF admission. The enrollee was medically
stable after a below knee amputation (BKA) with no evidence of need for supervision by a Physical Medicine
and Rehabilitation (PMR) Physician or needs acute rehab nursing care. She may benefit from further physical
therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission
is not medically necessary based on her current functional status and medical stability.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and physician services provided on August 5,2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit and physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 foran office visit and physician services provided on August 5, 2019 by anout of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,  training and supervision by a technician who is skilled in and who regularly and successfully usesthe appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued out-of-network ophthalmology care.You asked the Plan to pre-approve continued out-of-network ophthalmology care. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are qualified in-network ophthalmologists available to you than can treat your cataracts and glaucoma with a history of retinal detachment, corneal scar tissue, and other serious eye issues., teaching residents and medical studentswhile practicing ophthalmology.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-approvecare 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-approvecontinued out-of-network ophthalmology care.