Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve routine transportation services.
You asked the Plan to pre-approve routine transportation. You say that you have no other means of transportation and need to travel because there are no other providers in a reasonable distance to treat your condition. The Plan denied your request. The Plan says that the denial of authorization for routine transportation is correct, because this request is for 142 miles per trip, but the Plan only covers up to 50 miles per one-way trip.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles of driving distance per one-way trip. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify the exact destination you are requesting transportation to. The Plan did submit a map describing a trip by automobile, but the destination location included on this map is not related to the destination you described in your request. The Plan did not indicate that the destination you are requesting transportation to is not otherwise a Plan-approved location within the Plan's service area. The Plan's denial is purely on the basis that the mileage they estimated for the driving distance of each one-way trip exceeds 50 miles. Without the exact destination you are requesting transportation to, we cannot determine whether a one-way trip to this destination would fall within 50 miles of driving distance. Therefore, the Plan has not shown that its decision to deny authorization for this transportation is correct or justified based on your contract with the Plan. Therefore, we decided that the Plan has to pre-approve routine transportation services.
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 continued inpatient psychiatric care as of May 18, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says inpatient psychiatric care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient psychiatric level of care. Our physician reviewer found based upon the records provided it was not expected that the enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others. He did have hallucinations and delusions but was not showing any behavioral issues. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).
You asked the Plan to pre-approve MRgFUS. You say that this imaging would have value without the risk of surgery. The Plan denied your request. The Plan says your skull density is too low.
The Plan must follow Medicare rules. Medicare rules say that Magnetic Resonance Guided Focused Ultrasound Surgery System (MRgFUS) is not covered if a patient's skull density ratio (the ratio of cortical to cancellous bone) is less than 0.45. We looked at the file and Medicare rules. The record shows that your skull density is 0.38. Based on this information, we decided that Medicare rules for coverage of MRgFUS have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869,22870).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested service is investigational and non-covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a body mass index of 51.7. The Food and Drug Administration has stated in the product label that a body mass index above 40 is a contraindication to use of the requested device. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869,22870).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve the electric connection and power seat elevation system. We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the electric connection and power seat elevation system. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan says that the requested services are not medical in nature.
We decided that the Plan has to pre-approve the electric connection.
The Plan follows Medicare rules. Medicare rules say that codes E2310 and E2311 describe electronic components that allow the patient to control two or more of the following motors from a single interface. The file shows that the Plan has approved multiple power options, therefore the electric connection is covered. Therefore, we decided that the Plan has to pre-approve the electric connection.
We also decided that the Plan does not have to pre-approve a power seat elevation system.
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The requested equipment is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on October 1, 2020.
You asked the Plan to waive the copayment for these services. You say that you were told all copayments would be waived due to COVID. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit for laboratory tests.
Review of the file shows that you received laboratory services on October 1, 2020. You have been asked to pay a $20 copayment for these services. These services fall within the laboratory 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 the laboratory services rendered on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 that the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at or near his baseline and he can receive services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH admission. The Plan denied your request. The Plan says the enrollee has not completed a full hospital course of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be improving and should only require short-term additional acute care services for further weaning and resolution of ileus which can be safely provided at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum drainage system to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the in-network vendor is available to provide the requested equipment.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a vacuum drainage system to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case the enrollee was admitted to an acute care hospital due to altered mental status and edema. The enrollee has cryptogenic cirrhosis, significant cardiac disease, and acute kidney injury requiring dialysis. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: 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 disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that in order to receive covered post hospital SNF services, the beneficiary must have a medically necessary inpatient hospital stay for at least three consecutive calendar days. The Plan follows the same rule. We looked at the file and Medicare rules. The file shows that the enrollee had an inpatient hospital stay of two consecutive days prior to the SNF admission. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox to be obtained from a pharmacy.
You asked the Plan to pre-approve Botox. You say that this drug is medically necessary. 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 when obtained directly from a pharmacy and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox to be obtained from a pharmacy.
Benefits for Botox 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for various services provided to the enrollee on September 2, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records didn't include a detailed procedure note for the administration of these services.
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 the denied codes is: HCPCS A4222: Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) HCPCS A4624: Tracheal suction tube HCPCS A7001: Canister, non-disposable, used with suction pump, each HCPCS A7002: Tubing, used with suction pump, each HCPCS A9901: DME delivery, set up, and/or dispensing service component of another hcpcs code
HCPCS E0776: IV pole HCPCS E0780: Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours HCPCS E1399: Durable medical equipment, miscellaneous HCPCS J3490: Unclassified drugs CPT 99199: Unlisted special service, procedure or report HCPCS S1015: IV tubing extension set HCPCS S8301: Infection control supplies, not otherwise specified 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 services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records submitted do not include documentation in the operative note of a detailed procedure for the administration of HCPCS A4222, A4624, A7001, A7002, and A9901. The medical records do not include a complete description of the unlisted and unclassified codes (HCPCS J3490 and CPT 99199). The medical records do not include a valid physician order or a signed delivery sheet; therefore, HCPCS E0776, HCPCS E0780 and HCPCS E1399 cannot be verified. Per the 2020 National Physician Schedule Relative Value File July release, HCPCS codes S1015 and S8301 have a status indicator code of I and per the Medicare Claims Processing Manual 23  Fee Schedule Administration and Coding Requirements, Section 30.2.2  MPFSDB Status Indicators, I = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for various services provided to the enrollee on September 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID-19 pneumonia and acute respiratory failure. She required mechanical ventilation, feeding tube placement, and tracheostomy. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. The LTACH services 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says services can be received from providers in the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve medical oncology services to be provided by an out of network (OON) provider.