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

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is critically ill, and is receiving medically necessary care at the current 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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for multiple strokes having recently held her anticoagulant for a dental procedure. The enrollee required intubation/ventilation and subsequently received a tracheotomy. She remains on a ventilator. Given the location and severity of the enrollee's strokes, it is unclear that she will be able to e liberated from the ventilator or safely decannulated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and an Electrocardiogram (an EKG) to be provided by the out of network provider.
You asked the Plan to pre-approve an office visit and an EKG. You say that you would like to continue to see this provider because you are comfortable and have been seeing this provider for some time. The Plan denied your request. The Plan says the request is denied as there are in network providers associated with in network facilities that can perform this requested 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 pre-approve 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. 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-approve an office visit and an Electrocardiogram (an EKG) to be provided by the out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy (90837) to be provided by out of network provider.
You asked the Plan to pre-approve psychotherapy. You say that you developed a relationship with the out of network provider and you want to maintain services with her. The Plan denied your request. The Plan says you must have a behavioral problem that needs urgent or emergent attention. The Plan says you must have special needs or behavioral problems and there is not a provider in network who can take care of this problem. The Plans also says they found providers available in your network who are near where you live and can take care of your mental health problem.
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 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. 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-approve psychotherapy (90837) to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay, each (L3216), for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that the durable medical equipment is medically necessary. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. There is no evidence that the enrollee is using orthopedic hooks or braces and that orthopedic shoes are part of that equipment. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay, each (L3216), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hoyer lift, for the enrollee.
You asked the Plan to pre-approve the hoyer lift. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hoyer lift have not been met. Records provided show he has weakness and a spine problem. We did not get any other records to support this request. We need to know his muscle strength. We also must have a Certificate of Medical Necessity. Therefore, we decided that the Plan does not have to pre-approve the hoyer lift, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311).
You asked the Plan to pre-approve the dental services. You say that when the dentist removed your teeth you were advised the Plan covered it. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion - SI joint fusion (custom), for the enrollee.
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan denied your request. The Plan says the services are not necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found in this case the records provided for review only showed that the patient had undergone 1 SI joint injection to date (on October 16, 2019). In that regard the requirements of the LCD have not been met as the patient has not undergone "an image-guided, contrast-enhanced SIJ injection on two separate occasions". In as much the requirements of the LCD have not been met and the requested service would not be 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion - SI joint fusion (custom), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for diabetics only, fitting (including follow-up), custom
preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s),
per shoe (CPT Code A5500 x 2) and for diabetics only, multiple density insert, custom molded from model of
patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of
shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each (CPT
Code A5513 x 4).
You asked the Plan to pre-approve the foot orthotics. You say that you are pre-diabetic and you have burning
and numbness in your feet the past few years. The Plan denied your request. The Plan says the Medicare rules
have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the foot orthotics have not been met. Your information states that
you have neuropathy. This is pain caused by nerve damage. The requested diabetic shoes and inserts are not
medically necessary for your condition. The information submitted does not show that you have diabetes.
Therefore, we decided that the Plan does not have to pre-approve for diabetics only, fitting (including followup),
custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multidensity
insert(s), per shoe (CPT Code A5500 x 2) and for diabetics only, multiple density insert, custom
molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of
3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom
fabricated, each (CPT Code A5513 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transport chair, adult size, patient weight capacity up to and including 300 pounds (CPT Code E1038) and elevating leg rests, pair (for use with capped rental wheelchair base) (CPT Code K0195), for the enrollee.
You asked the Plan to pre-approve the transport chair. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the physician's letter of medical necessity satisfies medical necessity for a standard wheelchair. The Plan states there is no documentation addressing the need for a transport chair, and specifically why a standard wheelchair would not meet the enrollee's needs.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transport chair have been met. There is no documentation to indicate why a standard wheelchair would not be sufficient. Therefore, we decided that the Plan does not have to pre-approve transport chair, adult size, patient weight capacity up to and including 300 pounds (CPT Code E1038) and elevating leg rests, pair (for use with capped rental wheelchair base) (CPT Code K0195), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT Code K0861) and
accessories, for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. Based on review of medical records,
coverage of a wheel chair have not been met because the member does not have the inability to tolerate fully
upright sitting position, does not use intermittent catheterization, does not have limitation in ability to transfer
from wheelchair to elevate legs. Therefore, we decided that the Plan does not have to pre-approve power
wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and
including 300 pounds (CPT Code K0861) and accessories, for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the infrared therapy services you received from July 26, 2019 to August 8, 2019.
You asked the Plan to reimburse you for the services provided. The Plan denied your request. The Plan says the services were reimbursed based on your out-of-network benefits.
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% coinsurance for covered services out-of-network in Puerto Rico. The file shows that you were reimbursed the Medicare-allowed amount for each service at issue, minus your out-of-network coinsurance. The services fall within the physician services 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 reimburse you for the infrared therapy services you received from July 26, 2019 to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pertuzumab(J9306) and Trastuzumab-anns (Q5117). You asked the Plan to pre-approve Pertuzumab and Trastuzumab-anns. You say that the requested medications 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Pertuzumab and Trastuzumab-anns. Our reviewer says that the medications are not medically necessary. Our physician reviewer found trastuzumab with chemotherapy is approved for HER2+ serous carcinoma of the uterus. You have a carcinosarcoma of the uterus with primitive neuroectodermal tumor (PNET) component. The medications are not 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 Pertuzumab and Trastuzumab-anns have not been met.Therefore, we decided that the Plan does not have to pre-approvePertuzumab(J9306) and Trastuzumab-anns (Q5117).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on November 16, 2018.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says an Evidence of Benefit (EOB) is needed from the enrollee's primary insurance company.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the physician's services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for physician's services you provided on November 16, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transport service provided on August 20, 2019.
You asked the Plan to pay for the transport service. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the claim does not meet criteria for approval due to no evidence of service related given, no emergency room or life treat or risk, no pre-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. There is no evidence of service related given, no emergency room or life treat or risk, no pre authorization. Therefore, we decided that the Plan does not have to pay for the transport service provided on August 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care(CPT Code 99223) provided to the enrollee on August 8, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says this service was billed incorrectly.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The billed initial hospital care service, 99223, was denied because an observation care discharge service, 99217, has been paid for the subsequent date of service. According to policy, which is based on the AMA CPT Manual, initial hospital care codes are used to report inpatient hospital encounters, and observation care discharge day management is reported for discharge from "observation status." The billed initial hospital care service is inconsistent with the patient being in observation status, for which the observation care discharge service has been paid for the subsequent date of service.Therefore, we decided that the Plan does not have to pay forinitial hospital care (CPT Code 99223) provided to the enrollee on August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facelift surgery.
You asked the Plan to pre-approve facelift. You say that the enrollee does not like the way their skin sags. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the requested procedure is 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 pre-approve facelift. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records submitted have typical findings in association with facial aging and prior weight loss. The documentation does not support that there is a functional impairment associated with your condition. Specific rationale for a reconstructive surgery is not provided in the medical records. Medicare does not pay for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Based on the documentation provided, the planned procedure appears to be for aesthetic improvement and not treatment of a functional impairment. Therefore, this request does not meet Medicare criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facelift have not been met. Therefore, we decided that the Plan does not have to pre-approve facelift surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reaching/grabbing device, for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
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 reaching/grabbing device, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for manual wheelchair, for the enrollee.
You asked the Plan to pay for the manual wheelchair. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says records provided are illegible and, therefore, the Plan is unable to determinate medical necessity.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the manual wheelchair have not been met. The records provided are illegible and, therefore, we are unable to determinate medical necessity. Therefore, we decided that the Plan does not have to pay for manual wheelchair, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (CPT Code E2377), (CPT Code E2313) and (CPT Code E2311), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The notes state that these are needed when 3 or more actuators are being used.
The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Documentation shows that the member is able to perform dressing, self-feeding, grooming, hygiene, meal prep and IADLs independently at the wheelchair level. This upper limb strength and function is adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. The approved power options come with their own switches. Therefore, we decided that the Plan does not have to pre-approve (CPT Code E2377), (CPT Code E2313) and (CPT Code E2311), for the enrollee.