Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient services are met in this case. Our physician reviewer found there is no documentation provided necessitating inpatient hospital services for the elective procedure. The review has determined that the record does not show 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 not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be safely met in a skilled nursing facility or at home with home health. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for COVID 19 pneumonia. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. 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 documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone HCL ER 30mg tablet for the enrollee. 
 
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Oxycodone HCL ER 30mg 
tablet for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral supplies with CPT codes B4152 and B4034 provided from July 5, 2020 to July 26, 2020.
You asked the Plan to pay for CPT codes B4152 and B4034. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from May 13, 2020 to August 3, 2020. The Plan says, per Medicare guidelines, the provider needs to bill Original Medicare for the services rendered from July 5, 2020 through July 26, 2020.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the enteral supplies with CPT codes B4152 and B4034 provided from July 5, 2020 to July 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on July 7, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic radiology services provided on July 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waivethe $35 copayment charged for outpatient mental health care provided on February 21,2020.You asked the Plan to waivethis copayment. You say that you were not satisfied with the care you received.The Plan denied your request. The Plan says this copayment is a contractual obligation.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 $35 copayment for outpatient mental health services. The Plan has paid its share of the cost of this service per the Plan contract. 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 waivethe $35 copayment charged for outpatient mental health care provided on February 21,2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81227, 81230, 81231, 81232, 81240, 
81241, 81291, 81328, 81335, 81350, 81355) provided January 24, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says rules for telehealth have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the services ordered following the non-covered visit are likewise 
non-covered. Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81227, 
81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81350, 81355) provided January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is stable and ready for discharge to an LTACH. You say that the enrollee is expected to require another 3-4 weeks transitioning from acute illness before being able to transfer to a lower level of care. You say that an LTACH facility is safest for the enrollee.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's care could be provided in another setting.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 there isno documentation provided necessitating admission to a LTACH.  Th enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, 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. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a standard wheelchair. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not able to be approved. 
 
The Plan must follow Medicare rules. The rules say that a manual wheelchair is covered when there is a 
mobility limitation that cannot be resolved by a cane and/or walker, and the wheelchair will significantly 
improve the ability to complete MRADLs.  
 
The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 items. Our reviewer says that the 
requested items are not medically reasonable or necessary.  
 
Our physician reviewer found there is no documentation that your condition requires positioning of the body in 
ways not feasible in an ordinary bed. There is no documentation that you require frequent changes in body 
position, or immediate changes in body position. You do not require special attachments that cannot be fixed 
and used on an ordinary bed. There is no documentation showing medical necessity of a semi-electric hospital 
bed. 
 
Our physician reviewer found that there is no documentation of a mobility limitation that significantly impairs 
the ability to complete mobility-related activities of daily living (MRADLs). There is no documentation that 
the mobility deficit cannot be resolved by a cane and/or walker. There is no documentation that your home 
would be appropriate for a wheelchair, or that you (or a caregiver) could propel the wheelchair. There is no 
documentation that the requested wheelchair would significantly improve your ability to participate in 
MRADLs. The requested wheelchair 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed and a standard wheelchair.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a brain SPECT (78803).
You asked the Plan to pre-approve a brain SPECT. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a brain SPECT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found while the physician is of the opinion the most likely diagnosis is dementia, the DAT SPECT scan was ordered to make a firm diagnosis thus complying with NCD guidelines for the exam. 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 brain SPECT have been met. Therefore, we decided that the Plan has to pre-approve a brain SPECT (78803).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 28, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that your provider performed medically necessary 
services to the enrollee in good faith. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because this provider is out-of-network with the Plan and authorization was 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 for the medical services provided on February 28, 
2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 12 PT visits. 
 
You asked the Plan to pre-approve an additional 12 PT visits. You say that you are unable to lift your left arm 
above your head for the past almost three years. You say that you had a cervical fusion on December 5, 2019 to 
C3, 4 5, 6 and you had an EMG on August 24, 2020 that showed radiculopathy from C5 right and C4 left. You say that you have arthritis through your entire body and you had to retire in 2006 due to not being able to work. The Plan denied your request. The Plan says additional PT visits are not medically necessary per Medicare guidelines. 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 an additional 12 PT visits. 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 the requested additional therapy is not generally 
accepted as specific and effective therapy for your condition. You have had extensive therapy for this condition 
and it does not appear that you require the ongoing unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
under the supervision of a therapist.  
 
You should be able to transition to an independent home program at this point and the specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain your current condition or to prevent or slow further deterioration. 
 
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 additional 12 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 12 PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 10, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that the physician should be compensated for 
these services. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 the podiatry services provided on July 10, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for diagnostic colonoscopy and endoscopy services provided on July 23, 2020.
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment. The Plan denied your request. The Plan says this copayment is a contractual obligation for the services provided.
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 $250 copayment for outpatient diagnostic services. 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 $250 copayment charged for diagnostic colonoscopy and endoscopy services provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ophthalmological medical examination provided on June 
1, 2020. 
 
You asked the Plan to pay for the ophthalmological medical examination. You say that you were unaware the 
provider is out of network and you were not told that you needed prior authorization. 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 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 an ophthalmological medical examination provided on June 1, 
2020.