Persius/hicric huggingface dataset:
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 requires LTACH care. The Plan denied your request. The Plan says LTACH is 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 considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH for aspiration pneumonia. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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 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 portable oxygen system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the item at issue in this appeal performs the same function as equipment as currently used equipment.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found you have COPD and pulmonary fibrosis, and have a stationary oxygen concentrator and portable tanks for mobility within the home. Medicare does not cover portable oxygen for use outside the home; that is considered a convenience item. Medicare also does not cover duplicate equipment. A portable oxygen concentrator is therefore considered 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing services (96138, 96132, 96116, 96121).
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is medically necessary. The Plan denied your request. The Plan says the information does not show any evidence of an acute brain injury or other diagnosis that benefit from such testing.
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 neuropsychological testing. Our reviewer says that this patient had scored 20/30 on the MOCA on December 23, 2019 and 19/30 on January 28, 2020 which showed an intact global cognitive function. Her office visit on January 28, 2020 the patient stated that she is no longer experiencing any memory problems but stated that her memory issues began 6 months ago and lasted until 2 weeks ago. On review the records provided in the information provided this patient does not meet the criteria for neuropsychological testing as she claims no memory impairment and her underlying testing showed an intact global cognitive function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing services (96138, 96132, 96116, 96121).
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 enrollee needs rehab at an acute level in order to regain maximum function. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical and occupational therapy, but her functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ankle brace and a foot orthotic received on September 24, 2019.
You asked the Plan to waive the coinsurance for the items. You say that this should be paid for. The Plan denied your request. The Plan says the claim was processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. Additionally, 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. You have been asked to pay 20% coinsurance for the ankle brace. The brace falls within the durable medical equipment 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.
Additionally, the 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 waive the coinsurance for an ankle brace and a foot orthotic received on September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are unable to cook or bathe. You say that you live alone and have no assistance. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not require any additional skilled services that cannot be provided in an alternate setting. The Plan says that the enrollee does not have any skilled service needs that require a SNF setting.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee needs daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs. The enrollee is ambulating household distances and requires little assistance with mobility and transfers. While the enrollee may benefit from continuing physical therapy and occupational therapy, the records do not support the need for daily therapy. The enrollee's needs are custodial in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services received on June 8, 2018.
You asked the Plan to pay for the services. You say that you would like to be reimbursed. The Plan denied your request. The Plan says the claim was not filed timely.
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 the services was not filed until August 15, 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 for ambulance services received on June 8, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing provided to the enrollee on January 31, 2019.
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 payment for this testing is included in the payment for the already approved neuromonitoring.
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 95999 is " Unlisted neurological or neuromuscular diagnostic procedure ." As per records, this testing was train of four. We find that CPT code 95999 is not supported in the medical record. Specifically, this code is considered a bundled procedure, and it is included in the payment for the already approved/paid for neuromonitoring. 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 train of four testing provided to the enrollee on January 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig and mastectomy bra received on October 10, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a wig and mastectomy bra received on October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa 0.02% OPHTH solution for the enrollee.
You asked the Plan to pre-approve the solution. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered as it is self-administered.
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 Rhopressa 0.02% OPHTH solution for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care services received on October 3, 2019.
You asked the Plan to waive the copayment for the services. You say that the doctor did not provide good customer service. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
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 $35 copayment for Medicare-covered eye exams. You have been asked to pay a $35 copayment for the services. The services fall within the Medicare-covered eye exams 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 vision care services received on October 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810).
You asked the Plan to pre-approve the polysomnography. You say that the polysomnography is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this polysomnography (95810) duplicates the diagnostic portion of the approved split night study.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the polysomnography have not been met. Specifically, this service duplicates the diagnostic portion of the approved polysomnography (95811). Therefore, we decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment fora colonoscopy provided on September 3, 2019.You asked the Plan to waive the copayment fora colonoscopy. You say that this was a colonoscopy screening and you disagree with the charges.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The Planmust follow Medicare rules. Medicare covers 1 screening colonoscopy every 2 years or 1 barium enema every 2 years for people with high risk of colon cancer. An individual with a person history of adenomatous polyps meets the definition of "person with high risk of colon cancer" under Medicare rules. There is no evidence that this colonoscopy was ordered for diagnostic purposes or that any polyps were removed during this colonoscopy. The Plandid not submit any medical records from the ordering provider showing what type of colonoscopy was ordered or the reason it was ordered. A person with a personal history of polyps is considered to be at high risk of colon cancer. People at a high risk of colon cancer are eligible for screening colonoscopies under Medicare rules and these screening colonoscopies are covered at a greater frequency for those at high risk. No evidence has been submitted to show that your screening colonoscopy benefit was exhausted on this date of service. Based on the documentation submitted by the health plan, we find that you received a screening colonoscopy. Wefurther find that the Plan's contract provider incorrectly billed this colonoscopy as a diagnostic colonoscopy. Medicare rules say that, if a preventive service is covered with $0 cost-sharing under Original Medicare, the health plan cannot impose cost-sharing for the service when it is provided by in-network providers. Priority Health must follow this rule.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.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to waive the copayment fora colonoscopy provided on September 3, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePrednisone tablets.You asked the Plan to pre-approveself-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-approvePrednisone tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvevision care services provided on September 20, 2019.You asked the Planto pre-approvethe services. You say that you would like to get reimbursed.The Plandenied your request. The Plansaysnetwork providers must be used to get medical care and 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 pre-approve care from out-of-network providers only in cases involvingemergencies, 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 Plandoes not haveto pre-approvevision care services provided on September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSublocade injections.You asked the Plan to pre-approveSublocade injections. You say that the requested Sublocade injections are medically necessary.The Plan denied your request. The Plan says the requested Sublocade injections are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Sublocade injections. Our reviewer says that the requested Sublocade injections are not medically necessary. Our physician reviewer found the provided records showno support for switching from sublingual buprenorphine/naloxone to injected buprenorphine (Sublocade). There was no reported intolerance, inappropriate use, or report of other medications being used. There was no indication from the documentation that Sublocade would be any less or more safe than the currently used sublingual buprenorphine/naloxone.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sublocade injections have not been met.Therefore, we decided that the Plan does not have to pre-approveSublocade injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveLinzess 72mcg capsules.You asked the Planto pre-approvethe Linzess capsules. You say that this is medically necessary.The Plandenied your request. The Plansaysthis oral drug is not covered by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveLinzess 72mcg capsules.Benefits forthe Linzess capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.