Persius/hicric huggingface dataset:
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 records provided support the need for care in an IRF. You say that, without care in an IRF, you will be unable to regain maximum function, thus resulting in physical and mental duress. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs can be met at a lower, less intensive level of 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. 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 hematoma of the groin after recent lower extremity vascular studies and lower limb amputation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 additional visit for direct SN services of a RN in the
HH or hospice setting.
You asked the Plan to pre-approve the additional visit for direct SN services of a RN. You say that the enrollee
needs home health care. The Plan denied your request. The Plan says the requested service is not medically
necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional visit for direct SN
services of a RN. Our reviewer says that this service is not medically necessary for the enrollee. Our physician
reviewer found the records do not show that SN services are required to effectively provide treatment, care,
and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to
maintain the enrollee's condition and/or prevent deterioration beyond what was approved by the Plan. Our
reviewer found that the enrollee's condition is stable. Our physician reviewer also found that there are no
complex wounds or other SN needs. The enrollee was approved 2 out of the 3 visits which is ample time in
addition to his prior SN visits to have reviewed disease management training and education.
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 visit for direct SN services of a RN have not been met. Therefore,
we decided that the Plan does not have to pre-approve 1 additional visit for direct SN services of a RN in the
HH or hospice setting.
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 records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee does not require complex medical management. The Plan says that LTACH care 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. The enrollee is not intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available. 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 long term care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due
to her condition. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because CardioMEMS is experimental/investigational.
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 CardioMEMS. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in
only one randomized prospective trial to help reduce hospital readmission compared to standard medical
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. The device should still be considered
experimental/investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulse oximeter (E0445).
You asked the Plan to pay for the pulse oximeter. You say that you would like reconsideration because this
device is imperative in order to check your oxygen levels frequently. The Plan denied your request. The Plan
says this is not a Medicare covered device.
The Plan must follow Medicare rules. Medicare rules say that oximeters (E0445) will be denied as noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pulse oximeter have not been met. Specifically, oximeters are not a Medicare covered benefit.
Therefore, we decided that the Plan does not have to pay for a pulse oximeter (E0445).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 20 PT visits (G0151), 20 PT assist visits
(G0157), 20 HH RN visits (G0299), and 20 HH LPN visits (G0300) beyond the visits that were already
approved by the Plan.
You asked the Plan to pre-approve the additional PT visits, PT assist visits, HH RN visits, and HH LPN visits.
You say that you do not want to go into a nursing home. The Plan denied your request. The Plan says you do
not meet criteria for the additional nurse visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional PT visits, PT assist visits,
HH RN visits, and HH LPN visits. Our reviewer says that the additional visits are not medically reasonable and
necessary for you. Our physician reviewer found skilled nursing (SN) services are not required to effectively
provide treatment, care, and/or services in order to improve your condition, or to establish/perform a
maintenance program to maintain your condition and/or prevent deterioration. You have no complex wound
care or other ongoing SN need. You have had time to be educated in disease management. The requests for SN
are not medically necessary. The request for additional PT visits and physical therapy assist visits are not
medically necessary beyond what was approved by the plan. Our reviewer found that you do not require skilled
PT services to effectively provide treatment, care, and/or services in order to improve your level of function, or
to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration.
You have had extensive PT and your functional level does not require additional skilled therapy services
beyond what was approved by the Plan. Our physician reviewer also found that as the requested skilled therapy
and SN services are considered not medically necessary any request for home health aide services would also
be considered not medically necessary to the treatment of your 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 the additional PT visits, PT assist visits, HH RN visits, and HH LPN visits have
not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 20 PT visits
(G0151), 20 PT assist visits (G0157), 20 HH RN visits (G0299), and 20 HH LPN visits (G0300) beyond the
visits that were already approved by the Plan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasound scans and external electrocardiogram (EKG) monitoring provided from August 21, 2020, to September 22, 2020.
You asked the Plan to waive the copayments for diagnostic tests. You say that these bills are leaving you a huge debt. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $155 copayment for each radiological diagnostic test and $30 copayment for each non-radiological diagnostic test. For some of the billed services you have been asked to pay the allowed amount of the service, because this amount is less than the copayment amount.
Your total cost-sharing obligation is therefore $1,528.81.
You have been asked to pay $155 copayment or less for each radiological diagnostic test and $30 copayment for each non-radiological diagnostic test. Diagnostic tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for ultrasound scans and external electrocardiogram (EKG) monitoring provided from August 21, 2020, to September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of the CardioMEMS device.
You asked the Plan to pre-approve the implantation of the CardioMEMS device. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the CardioMEMS device 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 the implantation of the CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Therefore, the device should still be considered experimental or investigational. 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 implantation of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the knee provided on September 22, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you assumed this service was covered in full by your insurance. The Plan denied your request. The Plan says advanced imaging services, such as CT scans, are subject to a $150 copayment when provided in an outpatient hospital facility.
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 $150 copayment for advanced imaging services provided at an outpatient hospital facility. You have been asked to pay a $150 copayment for the CT scan. The CT scan was provided at an outpatient hospital facility and falls within the advanced imaging services 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 computed tomography (CT) scan of the knee provided on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this device due to her worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because CardioMEMS is experimental/investigational.
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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found data obtained from a CardioMEMS device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and it is not recommended for the treatment of heart failure. This device should still be considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS procedure
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from September 1, 2020, to September 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that your plan includes coverage for out-of-network chiropractic services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and this provider is not covered by the Plan's Point of Service (POS) benefit because they are within the Plan's service area.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that out-of-network services may be covered by the Plan's Point of Service (POS) benefit if the provider is outside of the Plan's service area. 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. This provider is within the Plan's service area and is therefore not covered by the Plan's Point of Service (POS) benefit. 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 for the medical services provided from September 1, 2020, to September 7, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexpen.
You asked the Plan to pre-approve a Flexpen. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a Flexpen is not covered under the enrollee's Medicare Part B benefit.
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 a Flexpen.
Benefits for a Flexpen 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the general health panel.
You asked the Plan to waive the copayment for the general health panel. You say that the general health panel
was performed at a specialist's office. The Plan denied your request. The Plan says the services were provided
by a freestanding laboratory.
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 for outpatient diagnostic tests and therapeutic services and supplies performed at a freestanding
laboratory.
You have been asked to pay a $20 copayment for the general health panel. The claim history reflects that these
services were provided by a freestanding laboratory. The general health panel falls within the outpatient
diagnostic tests and therapeutic services and supplies 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 general health panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary denture.
You asked the Plan to pay for the complete maxillary denture. You say that your current denture broke, and is
beyond repair. The Plan denied your request. The Plan says this request is considered a duplicate service. The
Plan also says that this service is only covered one time in a 60-month time period (5 years).
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary dentures (either code D5110
or D5130) are limited to one per 60 months. The records show that you received a complete maxillary denture
on May 31, 2019, and your maxillary dentures benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for a complete maxillary denture.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 18, 2020, to
October 2, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the documentation supports the
medical necessity of the inpatient stay. The Plan denied your request. The Plan says that the enrollee could
have been treated in a different level of care, such as observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights.
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 acute inpatient hospital care. Our physician
reviewer found that the enrollee presented to the emergency room on September 18, 2020, with dehydration
and weakness. He had been drinking heavily and not eating. On evaluation he required IV fluids and his EKG
was without acute changes. His troponins were normal. He was admitted and treated for alcohol withdrawal.
His electrolytes were stabilized, and he was discharged home when considered medically stable. The review
has determined that at the time of inpatient admission, the admitting physician reasonably expected that the
enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from September 18, 2020, to October 2, 2020.