Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on December 23, 2020.
You asked the Plan to waive the copayment for the laryngoscopy. You say that you were told you were going to a specialist and not a hospital. The Plan denied your request. The Plan says you have been asked to pay 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 $325 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $325 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an in-network outpatient hospital facility.
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 laryngoscopy provided on December 23, 2020.
Your complaint about fraud is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that your right foot has been partially deformed from birth and you have pain and discomfort daily. You say the requested physician has proven surgical expertise for very difficult foot surgeries like yours and this surgery is outside the scope of expertise available with a Plan provider. The Plan denied your request. The Plan says the services are available in-Plan and you are contractually required to obtain this service from network providers.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the patient does not meet criteria for SNF services.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on November 16, 2020.

You asked the Plan to waive the copayment for these services. You say that you should only have a specialist copayment. 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 $325 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.

Review of the file shows that you received outpatient surgery services at an ambulatory surgical center on November 16, 2020. Per the contract with the Plan, there is a $325 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $240.17. Given that the allowed amount was less than the $325 copayment, you have been asked to pay $240.17 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated wheelchair back cushion (E2617, E2609), lateral thigh or knee support wheelchair accessory (E0953), lateral trunk or hip support wheelchair accessory (E0956), and retractable swing away hardware (E1028).

You asked the Plan to pre-approve a custom fabricated wheelchair back cushion, lateral thigh or knee support wheelchair accessory, lateral trunk or hip support wheelchair accessory, and retractable swing away hardware. You say that these items are medically necessary.The Plan denied your request. The Plan says the enrollee has not demonstrated that standard seating options would not be effective.

The Plan follows Medicare rules. Medicare rules say that the custom seating options are subject to the criteria listed in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a custom fabricated wheelchair back cushion, lateral thigh or knee support wheelchair accessory, lateral trunk or hip support wheelchair accessory, and retractable swing away hardware. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 59 year old female with multiple medical conditions including neuropathy, chronic pain, and muscle weakness. A custom fabricated wheelchair back cushion (E2617, E2609) is not medically necessary as the documentation is not clear whether the patient has had a sufficient trial of a prefabricated seating system. The OT note is not clear on the duration of the trials and clear indications of why a prefabricated seating system is not sufficient to meet the patient's seating and positioning needs. Regarding the lateral thigh or knee support wheelchair accessory (E0953) and lateral trunk or hip support wheelchair accessory (E0956), the enrollee does not have significant postural asymmetries due to a diagnosis code listed in the policy article. Finally, since the base items E0953 and E0956 cannot be approved, the request for the swing away mounting hardware is not 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 a custom fabricated wheelchair back cushion, lateral thigh or knee support wheelchair accessory, lateral trunk or hip support wheelchair accessory, and retractable swing away hardware have not been met.Therefore, we decided that the Plan does not have to pre-approve a custom fabricated wheelchair back cushion (E2617, E2609), lateral thigh or knee support wheelchair accessory (E0953), lateral trunk or hip support wheelchair accessory (E0956), and retractable swing away hardware (E1028).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urine PCR panel rendered on March 11, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 

We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel rendered on March 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery services provided from May 4, 2020, through
May 5, 2020.

You asked the Plan to pay for surgery services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for surgery services provided from May 4, 2020, through May 5, 2020.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you do not meet complexity of nursing, medical management, and
rehabilitation requiring an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation
care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for ventricular tachycardia,
myocardial infarction, and congestive heart failure and was discharged home on April 6, 2021, with home
health services. You have ongoing weakness. Your medical problems are stable. There are no complex nursing
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria
for IRF 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: 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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission
.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. However, daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a SNF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the urology procedure.
You asked the Plan to pre-approve Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant (52441). You say that you feel you meet criteria for this procedure. The Plan denied your request. The Plan says the record show no previous conservative treatment and the prostate volume is greater than 80cc.
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 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant (52441). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria have not been met. Specifically, the prostate volume is greater than 80 cc and the patient has not failed medical therapy. Prostatic urethral lift is considered medically necessary for the treatment of symptomatic benign prostatic hyperplasia (BPH) when ALL of the following criteria are met: a. age 45 years or above, b. estimated prostate volume < 80 cc - no obstructive median lobe of the prostate identified on cystoscopy, c. failure, contraindication or intolerance to a trial of conventional medical therapy for BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant (52441) have not been met. Therefore, we decided that the Plan does not have to pre-approve the urology procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.
You asked the Plan to pre-approve an inpatient level of care for the approved surgery. You say that the requested inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care for the approved surgery 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 an inpatient level of care for the approved surgery. Our reviewer says that the requested inpatient level of care for the approved surgery is not medically necessary. Our physician reviewer found detailed documentation is not evident regarding significant risk factors for peri-operative complications. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for inpatient level of care is not medically reasonable or 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 an inpatient level of care for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an echocardiography.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there are no suggestions of an underlying structural cardiac abnormality.
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 procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have no active ischemic disease and have not had an intercurrent ischemic event since her last echocardiogram in 2/20. At her last exam in 9/20 she was stable without symptoms of signs of CHF on exam. Her echo in 2/20 was reportedly unchanged from a 2016 study as well. In the absence of changes in symptoms or signs of clinical CHF, new murmurs or intercurrent myocardial infarction, along with an echocardiogram with normal EF done one year prior, published guidelines and appropriate use criteria would not recommend a repeat echocardiogram as medically necessary or indicated based on this stable clinical history. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an echocardiography.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall and for atrial fibrillation with rapid ventricular response. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 26, 2020 by an out of network provider.

You asked the Plan to pay for the office visit. You say that the physician assumed authorization was obtained by the secretary. The Plan denied your request. The Plan says you did not request prior authorization

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 26, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided on October 1, 2020.
You asked the Plan to pay for hospital care. You say that this is supported in the records. The Plan denied your request. The Plan says this is part of the global surgical package for 47562.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for surgical procedures with the appropriate entry in Field 16 of the Medicare Fee Schedule Data Base (MFSDB) includes payment for preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. We looked at the file and Medicare rules. The record shows that the service at issue was a preoperative visit that took place the day before a major procedure, a laparoscopic cholecystectomy (47562). Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided on October 1, 2020.