Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services (00862QK) provided on March 11, 2019.
You asked the Plan to pay for the anesthesia services (00862QK). You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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. Specifically, the plan is denying payment for anesthesia services stating the provider is a pain management specialist billing as an anesthesiologist; however, the plan has not provided a denied claim for review or Medicare coverage criteria to support their reasoning for denial. There is no documentation in the case file showing that the provider is not an anesthesiologist. The Plan has failed to submit this case file in accordance to the rules set forth in the Part C Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual. Therefore, we decided that the Plan has to pay for the anesthesia services (00862QK) provided on March 11, 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 waive the coinsurance forthe aminolevulinic Acid HCL provided on August 23, 2019.You asked the Plan to waive the coinsurance forthis drug. You say that you were told your copay would only be $35.The Plan denied your request. The Plan says that you have a 20% coinsurance for drugs covered by Part B.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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for this drug. This drug falls within the Medicare Part B prescription drugs 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 coinsurance forthe aminolevulinic Acid HCL provided on August 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee underwent total knee replacement and was readmitted with urinary tract infection. The enrollee is participating in physical therapy as an outpatient. The enrollee is not receiving home health skilled nursing services. Based on available records, the enrollee does not meet criteria for coverage of the requested home health aide. The enrollee is not confined to the home. The enrollee does not have any home health skilled nursing or therapy needs. The home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care after December 4, 2019 through January 23, 2020.
You asked the Plan to pre-approve SNF care. You say that the stay was 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. The provided medical records do not indicate a need for inpatient services. Care in the long term care facility with custodial care and intermittent therapy appears to be appropriate. 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 continuation of SNF care after December 4, 2019 through January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 8, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services.
You asked the Plan to pre-approve the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services. Therefore, we decided that the Plan does not have to pre-approve laboratory services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeve (L2397) provided to the enrollee on June 10, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support the 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 pay for the orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthoses were medically reasonable and necessary for the enrollee in this case. A current history and a physical examination of the wrists would reasonably be required to adequately assess whether the wrist/hand orthoses were medically reasonable and necessary. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is insufficient documentation of a current physical examination of the wrists. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeve (L2397) provided to the enrollee on June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient mental health services provided on June 17,2019 to July 8, 2019. You asked the Plan to pay forthe inpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the admission was voluntary and non-emergent. There was no preauthorization. The Enrollee has no out-of-network benefits.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 forthe inpatient mental health services provided on June 17, 2019 to July 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional months of Fasenra treatments for the enrollee.
You asked the Plan to pre-approve additional treatments. You say that the enrollee needs Fasenra to decrease asthma symptoms and chances of hospitalization. The Plan denied your request.
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. The file shows that 12 months of Fasenra treatments were requested. The Plan has agreed to pre-approve 6 months of treatments. 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 additional treatments. Our physician reviewer found that the enrollee has a diagnosis of asthma. She has had 2 exacerbations in recent months, and persistent symptoms despite maximum medical therapy. The eosinophil count is 186. Treatment with Fasenra is considered reasonable and necessary for this enrollee, and a 6-month trial is reasonable. The enrollee can then be re-assessed. If the enrollee is benefiting from the drug, continuation can be approved at that time. Therefore, the request for additional Fasenra is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional months of Fasenra treatments for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have pre-approve ten additional PT sessions.
You asked the Plan pre-approve ten additional PT sessions. The Plan denied your request. The Plan says additional PT is not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten additional PT sessions. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found for neck and back pain, PT is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed 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 additional PT sessions have not been met. Therefore, we decided that the Plan does not have pre-approve ten additional PT sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental appliance/sleeve (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeve. You say that coverage was denied as not medically necessary and you respectfully disagree.The Plan denied your request. The Plan says the enrollee has not had a four week trial of an E0650 or E0651 and does not meet the criteria. Since the pneumatic compressor is not covered, the appliance/sleeve (E0667) will also not be covered.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 responseto 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 thePCD 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 uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmental appliance/sleeve (E0667).
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 medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not need intensive rehabilitation program. Member can stay at the acute hospital for continued treatment of C. diff colitis and hyperglycemia.
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 was medically unstable and is too sick to be admitted to an IRF. She may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. IRF admission is not medically appropriate at this time based on her and medical 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 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 preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.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 treatmentwith 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 notbeen 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 uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 23, 2019.
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 documentation submitted did not include a valid physician order/lab requisition or medical records signed by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on May 23, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide $1000 ($500 for each ear) reimbursement for the hearing aids purchased on July 22, 2019
You asked the Plan to provide $1000 reimbursement for the hearing aids purchased on July 22, 2019. You say that you are requesting reimbursement of hearing aids purchased. The Plan denied your request. The Plan says that the Medicare rules have not been met.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have been met. Based on the submitted documentation, your reimbursement request meets contract criteria. Your EOC clearly states, that you may receive the following services from any hearing or hearing aid provider: Plan approved hearing aid(s) (2 per calendar year). You pay any amount over $1000 ($500 per ear). Therefore, we decided that the Plan has to provide the total $1000 reimbursement ($500 for each ear) for the hearing aids purchased on July 22, 2019
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a calcaneus ostectomy (28118) provided on July 19, 2019.
You asked the Plan to pay for a calcaneus ostectomy. You say that this code is supported by the medical records. The Plan denied your request. The Plan says there is a more appropriate code for the service performed.
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 28118 is ostectomy, calcaneus. 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 a calcaneus ostectomy. Our reviewer says that CPT 28118 is not supported by the medical records. Our physician reviewer found the submitted documentation does not contain evidence that the enrollee underwent an ostectomy of the calcaneus. 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 calcaneus ostectomy have not been met. Therefore, we decided that the Plan does not have to pay for a calcaneus ostectomy (28118) provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab tests provided on July 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab tests. You say that this is a request to review your policy concerning reference laboratories and re-process our claim for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was also not obtained.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 foroutpatient lab tests provided on July 23, 2019 by an out of network (OON) provider.