Persius/hicric huggingface dataset:
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 this is the safest discharge plan for the enrollee, as it allows her the highest potential level of function for recovery. You say that an LTACH admission will help prevent further deterioration and is the best use of medical management.The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.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 foundthe enrollee is currently undergoing treatment at an acute care hospital (ACH) for multifactorial shortness of breath. The enrollee is receiving antibiotics and her usual hemodialysis. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that 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 lookedat 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out-of-network physical therapy services. You say that your clinic offers one-on-one, hands-on, skilled physical therapy services. You say that your clinic provides high-skilled services that ensure the enrollee's treatment will be efficient and tailored to his needs. You say that you expect the enrollee to gain function, improve pain levels, and have an overall improvement in his quality of life.The Plan denied your request. The Plan says medically necessary care is available in-network.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.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRestasis Emulsion 0.05%.You asked the Plan to pre-approveRestasis. You say that the medication is medically necessary.The Plan denied your request. The Plan says coverage for this type of drug is not available under the Part B Medical 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-approveRestasis Emulsion 0.05%.Benefits for Restasismay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are unable to be left alone and need skilled nursing level of care. The Plan denied your request. The Plan says that your clinical condition does not require skilled nursing level of care as inpatient.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe WATS 3D brush biopsy rendered on July 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has adenomatous and hyperplastic rectal polyps as well as colon diverticulosis. There is no documentation or history of Barrett's esophagus. The use of the WATS-3D Brush Biopsy in the absence of thsi diagnosis is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pay forthe WATS 3D brush biopsy rendered on July 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-networkprovider.You asked the Plan to pre-approvethese services. You say that the enrollee is homebound and no other providers will go to their residence.The Plan denied your request. The Plan says the services are available from networkproviders.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.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee forthe over-bed table, bath/shower chair, stander security pole and grab bar, and bed cradle from July 16, 2019 to August 7, 2019.You asked the Plan to reimburse the enrollee forthe durable medical equipment.You say that it takes too long to get items from a network provider.The Plan denied your request. The Plan says a company you went through not a Medicare certified supplier and therefore no payment can be made.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or providerwho has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that  a company entered into a private contract with the enrolleeregarding payment.Therefore, we decided that the Plan does not have to reimburse the enrollee forthe over-bed table, bath/shower chair, stander security pole and grab bar, and bed cradle, purchased from a company from July 16, 2019 to August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital admission.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says this can be done in outpatient or observation status.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found in the case, following evaluation in the ER, heart block was diagnosed and you were placed under observation status awaiting confirmation with cardiology as you might need a pacemaker which was confirmed the next day. During the ER stay and following day under observation, no major emergency occurred and no complex surgery or complication related to the pacemaker surgery was expected or took place to justify a full admission status. The expected care was not expected to span at least 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 pay for inpatient hospital admission.
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-approvetheLTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following emergency surgery for a ruptured abdominal aorta. The enrollee was intubated/ventilated for surgery, but has since been extubated and is no longer on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, 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.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: Lab
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 August 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 August 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refraction state (92015) provided September 24, 2019.You asked the Plan to pay for refraction services. You say that your records should show you that you had eye surgery and the number of times you have been trying to get the correct eyeglasses prescription that allows you to see clearly.The Plan denied your request. The Plan says the maximum benefit has been exhausted.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when routine eye exam, including refraction, is limited to once a year..We looked at the file and the Plan's rules. The records show that this service was provided on January 16, 2019. Based on this information, we decided that the Plan's rules for coverage of refraction services have not been met.Therefore, we decided that the Plan does not have to pay for determination of refraction state (92015) provided September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical esophageal sphincter augmentation procedure (CPT 43284) for the enrollee.You asked the Plan to pre-approvethe procedure. You say that the plan has taken away the enrollee's right to receive the treatment plan preferred by the surgeon.The Plan denied your request. The Plan says medical studies have not proven that this service is helpful for treatment of the health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the LINX device is not FDA-approved for the setting of Barrett's esophagus. Accordingly, re-implantation of LINX in the enrollee's circumstance must be approached with caution and cannot be considered medically necessary nor appropriate given his documentation of Barrett's esophagus in which the safety and efficacy of LINX has not been established. Removal of the existing LINX device which has migrated is medically appropriate and has been plan-approved.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvethe surgical esophageal sphincter augmentation procedure (CPT 43284) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan supartz (J7321).You asked the Plan to pre-approve the Hyalgan supartz. You say that this service is medically necessary for the treatment of the member's condition. The Plandenied your request. The Plan says the member does not meet Medicare coverage criteria for this service. 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 Hyalgan supartz. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has not had an adequate trial of conservative therapy.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 Hyalgan supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan supartz (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on October 21, 2019.You asked the Plan to pay for the dental services. You say that your hygienist recommends that you have a cleaning every 4 months. You also say that the hygienist you see is the only one that does not use a machine, which you've been burned by in the past.The Plan denied your request. The Plan says the maximum benefit has been reached.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 and oral exams and cleanings are covered services, the benefit maximum of 1 cleaning and 1 oral exam every 6 months has been reached.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for Prolia 60mg/ml Syringe.You asked thePlan to pre-approvethe tier exception for Prolia. You say that the drug is medically necessary and a tier exception should be granted.The Plan denied your request. The Plan says tier exceptions are not available for this drug.The Plan must follow Medicare rules. Medicare rules say that some Part D drugs are eligible for Tier exceptions. We looked at the file and Medicare rules. The requested drug is a Medicare Part B Prescription Drug. Part B Drugs are not eligible for a tierexception. Based on this information, we decided that Medicare rules for coverage of the tier exception for Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approvea tier exception for Prolia 60mg/ml Syringe.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the office visits and therapeutic prophylactic injection. We decided that the Plan does not have to waive the coinsurance for and triamcinolone acetonide injection.
You asked the Plan to waive the cost share for the office visits, therapeutic prophylactic injection and triamcinolone acetonide injection. You say that you have never seen the provider and never had injections. You say that you thought you were having blood work done not an office visit. The Plan says that the cost share applied correctly.
We decided that the Plan has to waive the copayment for the office visits and therapeutic prophylactic injection.
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 pay a $0 copayment for a primary care physician. The records show that the provider works at a family medicine office. Therefore, we decided that the Plan has to waive the copayment for the office visits and therapeutic prophylactic injection.
We also decided that the Plan does not have to waive the coinsurance for the triamcinolone acetonide injection.
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% coinsurance for each Medicare-covered Part B drug. The allowed amount of the triamcinolone acetonide injection is $1.56 (20% x $1.56 = $0.31). Therefore, we decided that the Plan does not have to waive the coinsurance for the triamcinolone acetonide injection.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD) for the enrollee.You asked the Plan to pre-approvea HFCWOD. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have any of the covered problems.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the enrollee has COP, which is not a diagnosis for which this treatment has been shown to be effective. The enrollee does not have cystic fibrosis, bronchiectasis, or generalized neuromuscular disease. He does not use an in-ex-sufflation device. HFCWOD is considered 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 a HFCWOD have not been met.Therefore, we decided that the Plan does not have to pre-approvea high frequency chest wall oscillation device (HFCWOD) for the enrollee.