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

We decided that the Plan does not have to pay for the skilled nursing services provided from July 1, 2019 to July 30, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 daysper benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from April 24, 2019 and September 20, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from July 1, 2019 to July 30, 2019
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvethe removal of a lap band (43772). You asked the Plan to pre-approve the removal of a lap band. You say that this is medically necessary.The Plan denied your request. The Plan says that there is not evidence that the enrollee has a major complication.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the removal of a lap band. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the lap band is a foreign body and maximal efforts to deflate the fluid have already been documented. Although there is no overt anatomic complication of the device, the patient continues with gastroesophageal reflux disease(GERD), vomiting,and dysphagia. The only way to fully correct this is surgical removal of the device, as maximal conservative efforts have already been attempted. The standard of carewithin the medical community islap band removal for correction of anatomic complications,but also when there are negative symptoms such as worsening GERD, dysphagia or vomiting as these are not sustainable long term and risk harm to the patient. Lap band removal for correction of dysphagia and GERD are well published and accepted within the medical community. It is not investigational or for the convenience of the patient or provider.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 removal of a lap band have been met.Therefore, we decided that the Plan has to pre-approvethe removal of a lap band (43772).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided to the enrollee from September 1, 2019, to September 4, 2019.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the enrollee could have been safely discharged directly from the Emergency Department to a skilled nursing facility.
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 pay for the outpatient services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee arrived at the ED on September 1, 2019, with reported weakness. History and examination showed no localized signs or symptoms. Vitals were stable, blood tests were essentially normal, EKG was normal, and chest x-ray did not reveal any acute abnormality likely related to the weakness. According to the provided documentation, he stayed under observation care status for monitoring until placement for a nursing home was confirmed. However, the enrollee was clinically stable for discharge on September 1, 2019. Therefore, the requested outpatient observation services were 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 outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient services provided to the enrollee from September 1, 2019, to September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 18, 2019.You asked the Plan to pay forthe laboratory testing. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services provided are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory testing provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a group three power wheelchair for the enrollee.You asked the Planto pre-approve the wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee does not have a qualifying diagnosis.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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a personal mobility deficit that impairs participation in MRADLs. The enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair as she is unable 
to stand out of a wheelchair since 2006. She is noted not to have the coordination to propel a manual wheelchair. The documentation does not reveal a home assessment that indicates the enrollee is able to safely operate a PMD. The documentation reveals that the enrollee was ambulatory until 2006 when she had patellar dislocations and an ankle fracture in 2008. The documentation does not reveal that her mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. The request for a Group 3 wheelchair is 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 wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea group three power wheelchair for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services provided on May 7,
2019.
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not separately
payable.
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 99232 is subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused examination; Medical decision making of
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.
We find that CPT code 99232 is not supported in the medical record. Specifically, this service is included in the
global surgical package. When an evaluation and management visit is reported within 90 days of the major
surgical procedure, it will be bundled as part of the global surgical fee. Based on this information, we decided
that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we
decided that the Plan does not have to pay for the subsequent hospital care services provided on May 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on June 11, 2018.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the record does not support necessity. The Plan must follow Medicare rules. Medicare rules say that the Medical records must support the need for the prescribed equipment. The medical information provided does not corroborate the prescription. The primary care physician indicated on November 11, 2019 that the back brace was ordered in error. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on June 11, 2018
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 10, 2019 to July 26, 2019.You asked the Plan to pay for the services. You say that this is medically necessary.The Plan denied your request. The Plan says as a practical matter, daily skilled services did not only have to be provided on an inpatient basis in the SNF.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 pay for the services. 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 enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis 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 the services have not been met.Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 10, 2019 to July 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on September 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that this wound care is provided at a skilled nursing facility. You say that the enrollee has no choice of which provider should come see him. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 referring nursing home is also out-of-network. 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 wound care provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs to get his strength back to become independent again.The Plan denied your request. The Plan says the enrollee's medical condition is stable, and requires minimal assistance with bed mobility and transfers.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 physician reviewer found that the enrollee has suffered recurrent falls and has left thigh neuropathic pains. Imaging revealed L4-5 disc prolapse. He was managed non-operatively. He is hemodynamically stable. 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 is at minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Venofer for the enrollee.
You asked the Plan to pre-approve Venofer. You say that the enrollee has not been able to keep her ferritin levels at adequate levels, requiring Venofer infusions. The Plan denied your request. The Plan says that there is no supported compendia or meet FDA criteria for the requested drug.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Venofer. Our physician reviewer found that the enrollee has diagnoses for restless leg syndrome (RLS) and other disorders of iron metabolism. Low serum ferritin concentrations have been associated with increased severity of symptoms in patients with restless legs syndrome. Iron replacement is suggested in patients with RLS when the fasting serum ferritin level is less than or equal to 75 mcg/L. Iron supplementation may be supplied orally or intravenously. In this case, it is documented that the enrollee had a serum ferritin level of 58 ng/mL on April 29, 2019, and that she does not tolerate oral iron. The documentation supports that Venofer is expected to be safe and effective, and otherwise reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Venofer have been met. Therefore, we decided that the Plan has to pre-approve Venofer for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 10, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you previously had laboratory work and did not have a copayment. You say that you were not aware the laboratory work would require an additional copayment. The Plan denied your request. The Plan says the copayment 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 $20 for Medicare-covered laboratory tests. You have been asked to pay $20 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on September 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on October 1, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that since the enrollee was not treated properly, he should not have to pay for the ambulance transport back to the hospital. The Plan denied your request. The Plan says that benefits were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copay per one-way trip for Medicare-covered ambulance services. The enrollee has been asked to pay less than a $295 copay for the ambulance transport. The ambulance transport falls within the one-way trip for Medicare-covered ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an OON provider.
You asked the Plan to pre-approve the medical services. You say that your primary care physician recommended a third opinion since you complained that previous ophthalmologists did nothing. The Plan denied your request. The Plan says your medical records do not show your current condition is urgent or needs emergency attention. The Plan states you have local providers in your network within a reasonable distance from your location that can provide this service. The Plan states you have an approved authorization for a second opinion eye exam with your local network provider.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. You have local providers in your network within a reasonable distance from your location that can provide this service. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an OON provider.