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

We decided that the Plan does not have to waive the copayment for lab work provided by a participating freestanding facility on October 21, 2020.

You asked the Plan to waive the copayment for lab work. You say that this should be a $0 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests/lab services/freestanding laboratory. 

You have been asked to pay a $20 copayment for lab work. The correct copayment has been applied to the lab work that was provided at a contracted freestanding facility. Lab work falls within the outpatient diagnostic tests/lab services/freestanding laboratory benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab work provided by a participating freestanding facility on October 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says services can be provided at an observational level of care.

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 it is not expected that the patient would require treatment in the hospital that would cross 2 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. Specifically, it is not reasonable to believe the enrollee's inpatient stay would span two midnight's. This means admission to an inpatient hospital is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960).

You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for payment have 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 pay for a shoulder-elbow-wrist-hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that, based on the medical records provided, there is no documentation of an in-person physician examination to certify that the orthosis in this case is medically reasonable and 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 shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the toggle switches coded as K0108 to be provided with an approved power wheelchair.
You asked the Plan to pre-approve the toggle switches. You say that all requested items are medically necessary. The Plan denied your request. The Plan says all items were approved aside from the toggle switches described by K0108 as this is included in payment for the expandable controller.
The Plan must follow Medicare rules. Medicare rules say that no component of an expandable controller can be coded with K0108 at the time of initial issue. Therefore, we decided that the Plan does not have to pre-approve the toggle switches coded as K0108 to be provided with an approved power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of impacted tooth (D7220).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth (D7220).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.
You asked the Plan to pre-approve the shower. You say that you need this are you are unable to get inside a regular bathtub. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower.
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 enrollee needs IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While The patient does require physical therapy and occupational therapy services, based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Finally, based on the medical records provided there is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because you have intense pain in your feet and have gotten painful callouses from the way you walk without the orthotics. 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 who wear 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 pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 based on the medical records, the enrollee is more stable and should not require more than short-term additional acute care services which can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Medicare coverage criteria for transfer are not met. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crown fused to high noble metal (tooth 3) (D2740).

You asked the Plan to pre-approve the dental service. You say that you were told this was covered once every 5 years. You swallowed it by accident and don't have it anymore. You got a filed down tooth with no crown. #3 was denied but the others were approved. The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.

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. This service is allowed once every 60 months. The records show this service was already provided within the 60 month time period. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit at this time. Therefore, we decided that the Plan does not have to pre-approve porcelain crown fused to high noble metal (tooth 3) (D2740).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 11, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 diagnostic radiology services provided on September 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided on November 4, 2020 and November 11, 2020.
You asked the Plan to pay for psychiatric services (90791). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the submitted taxonomy corresponds to Licensed Professional Counselor which is not recognized as payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Original Medicare does not allow all professionals to directly submit charges for the services that they provide. We find that your provider type is SP and therefore not recognized as payable by Medicare. Based on this information, we decided that Medicare rules for coverage of psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for psychiatric services provided on November 4, 2020 and November 11, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at an alternate level of care.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve capecitabine 500mg tablets.

You asked the Plan to pre-approve the capecitabine tablets. You say that this treatment is medically necessary. The Plan denied your request. The Plan says as this will be provided through a clinical trial, it cannot be authorized by the Plan. The routine costs of this trial should be billed to the Original Medicare contractor.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve the capecitabine tablets as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve capecitabine 500mg tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gene analysis for the HFE gene for hereditary hemochromatosis described by code 81256.

You asked the Plan to pre-approve the HFE gene analysis. You say that it is felt this testing should be done due to lack of access to prior records. The Plan denied your request. The Plan says the results of prior testing are known. It is not reasonable and necessary to perform this analysis more than once for this patient.

The Plan follows Medicare rules. Medicare rules say that HFE gene analysis may be covered once per lifetime for those with iron overload of uncertain etiology. 

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 HFE gene analysis. Our reviewer says that the requested testing is not considered medically reasonable and necessary due to prior testing for this gene. Our physician reviewer found the enrollee is an 80-year-old man with a history of chronic lymphocytic leukemia, hemochromatosis, and prostate cancer. The hemochromatosis was diagnosed in 1998 via liver biopsy. There was documentation from the previous hematologist office that the HFE gene testing showed combined heterozygous for the H63D and C282Y mutations. On 3/1/21 the enrollee was clinically doing okay with no major health issues. The enrollee's hematologist/oncologist writes that the previous medical records were not available confirming the diagnosis. The results are documented would not be expected to change from prior testing. There is not sufficient medical need to confirm the prior reported test results as he is clinically stable at this time. 

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 HFE gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve gene analysis for the HFE gene for hereditary hemochromatosis described by code 81256.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 21, 2021 with gangrene of the right great toe and a right groin wound with a surgical site infection. She is weak and deconditioned and is working with physical and occupational therapy. She needs assistance with walking 25 feet, transfers, and activities of daily living. The records do not support that 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. She does require further therapy but does not require an intensive therapy program 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided by the physician.

You asked the Plan to pre-approve foot orthotics. You say that the enrollee has a leg length discrepancy. 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 who wear 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 pre-approve foot orthotics provided by the physician.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta solution.

You asked the Plan to pre-approve Vyzulta. You say that this medication is medically necessary because it has controlled the enrollee's eye pressure. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Vyzulta solution.

Benefits for Vyzulta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.

You asked the Plan to pre-approve home health skilled nursing visits. You say that home health care services
are medically necessary. The Plan denied your request. The Plan says home health visits are no longer
necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve home health skilled nursing visits. Our
reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer
found based on the documentation provided, the enrollee does not have documented skilled nursing needs.
Therefore, the provision of ongoing home health skilled nursing services is not medically necessary or
reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health skilled nursing visits.