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 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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do not require this or appear to be able to tolerate this on an intensive rehabilitation facility therapy program level 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: 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 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 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) following surgery for a perforated bowel after a recent colonoscopy. The enrollee is now exhibiting altered mental status and failure to thrive. The enrollee is not intubated/ventilated. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you want to appeal the Plan's denial of the requested diapers and supplies.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from September 2, 2019 to October 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered with code 85. We looked at the file and Medicare rules. The claims were not billed with the required FIPS code. 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 for the home health services rendered to the enrollee from September 2, 2019 to October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approvea shower chair. You say that you really need the requested shower chair to help you with your daily activities.You say that you have two denied claims. The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 21, 2020.You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before February 21, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services after February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLife2000 Ventilator System.You asked the Plan to pre-approveLife2000 Ventilator System. You say that you need the Life2000 Ventilator System in order to leave the house.The Plan denied your request. The Plan says the Life2000 Ventilator System is not considered a ventilator or another type of positive airway pressure device.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 Life2000 Ventilator System. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found The "Life2000" open ventilator system is considered not medically necessary. There is inadequate evidence that this device is beneficial in the treatment of COPD or pulmonary hypertension. It is not a true ventilator. A medical need for a ventilator, or for BiPAP, has not been established. There are no arterial blood gas data to document hypercarbic respiratory failure.  There are no overnight oximetry data documenting nocturnal hypoxemia while on CPAP with supplemental oxygen. The denial is upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Life2000 Ventilator System have not been met.Therefore, we decided that the Plan does not have to pre-approveLife2000 Ventilator System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for new balance sneakers purchased February 12, 2019.You asked the Plan to pay fornew balance sneakers. You say that the provider did not know the process so they were unable to submit the authorization request and you request reconsideration.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients whowear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay fornew balance sneakers purchased February 12, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 4, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that the test was given to you on November 1, 2019 and you returned it on November 4, 2019. You feel that the test should be covered under the $20 maximum for laboratory tests per day.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 laboratory tests. You have been asked to pay the allowed amount of $15.02, which is less than the $20 copayment for laboratory services. Laboratory services 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 acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services provided on November 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea percutaneous left atrial appendage (LAA) closure therapy procedure (33340). You asked the Plan to pre-approvea percutaneous LAA closure therapy procedure. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 a percutaneous LAA closure therapy procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided the enrollee has atrial fibrillation tolerating Xarelto and no documented medical condition that would increase bleeding risk as well as no medical contraindication that would preclude continued anticoagulation. Driving all-terrain vehicles is a lifestyle choice and not a medical condition. In this circumstance the criteria are not met since appropriate selection for a Watchman device includes enrollees with elevated CHAD risk who are unable to tolerate anticoagulation or who have a medical condition that would prohibit use of anticoagulation, neither of which is documented 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 a percutaneous LAA closure therapy procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea percutaneous left atrial appendage (LAA) closure therapy procedure (33340).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on November 22, 2019 by an out of network (OON) provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that these services were medically necessary.The Plan denied your request. The Plan says these 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe domiciliary or rest home visit provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on November 18, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no valid referral for this service
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 nurse practitioner services provided on November 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services (90834).You asked the Plan to pay for the mental health services. You say that you would like reconsideration as this member has been provided a safe space to develop. The Plan denied your request. The Plan says Medicare does not cover behavioral health services provided by Licensed Marriage and Family Therapists (LMFT).The Plan must follow Medicare rules. Medicare rules say that The rules say that Part B covers mental health services and visits with Psychiatrists or other doctors,  clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners and physician assistantsWe looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mental health services have not been met. Specifically, Medicare does not cover behavioral health services provided by LMFTs. Therefore, we decided that the Plan does not have to pay for mental health services (90834).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord nerve stimulator (63650, L8680, 63685).You asked the Plan to pre-approvea spinal cord nerve stimulator. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has notbeen met.The Plan follows Medicare rules. Medicare rules say that electrical nerve stimulators are covered when specific criteria is met.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 spinal cord nerve stimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the criteria of the National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7). The documentation does not reveal objective evidence of a psychological screening evaluation therefore the request for a spinal cord stimulator cannot be 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 a spinal cord nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal cord nerve stimulator (63650, L8680, 63685).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan Tab 550mg.
You asked the Plan to pre-approve Xifaxan Tab 550mg. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Xifaxan Tab 550mg.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that someone had called for an ambulance
because you had passed out and your blood pressure was low. You say that you refused to go to the hospital or
ride in the ambulance so you feel like you should not be responsible for the bill. The Plan denied your request.
The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on December 5, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 to October 7, 2019 by anout of network (OON) provider.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 rendered by a non-contracted provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 to October 7, 2019 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pontic (D6240).You asked the Plan to pre-approvethe dental item. You say that your top teeth are decaying. You say that some teeth are broken. You also say that you need some top teeth removed. You say that you need these services so that you can eat and have a full mouth of teeth to chew.The Plan denied your request. The Plan says pontics are not listed as a covered service.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, the requested pontic is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea pontic (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove the intermittent limb compression device.
You asked the Plan to preapprove an intermittent limb compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the conservative methods that Medicare requires.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Additionally, there must be a four-week trial of conservative therapy. The file does not show that the enrollee has had four-week trial of other clinical treatment including appropriate compression garments, exercise and elevation. Therefore, we decided that the Plan does not have to preapprove the intermittent limb compression device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of acellular amnion fluid allograft (Flower-Amnio-Flo).You asked the Plan to pre-approveFlower-Amnio-Flo. You say that you have 2 bad knees and cannot get them operated on, and you have no other alternatives.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is considered experimental/investigational for your condition.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 Flower-Amnio-Flo. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service continues to be investigational for your condition. At this time additional research and basic science is needed to determine the clinical efficacy of amniotic tissue product in symptomatic osteoarthritis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Flower-Amnio-Flo have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of acellular amnion fluid allograft (Flower-Amnio-Flo).