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

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that you do not meet
the criteria for admission to an Inpatient Rehabilitation Facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 that based on the documentation provided, it is my opinion that the health Plan's
denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met at a lower level of care (ex. skilled nursing facility, sub-acute rehab).
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 IRF admission and services.
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).

You asked the Plan to pre-approve a HFCWOD. You say that please reconsider this request for the Monarch portable HFCWO technology. The Monarch vest is medically necessary for the enrollee's management of his fragile pulmonary health. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for coverage.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found In this case the enrollee has asthma and chronic obstructive pulmonary disease. A CT scan has demonstrated bronchiectasis. The enrollee has not been performing airway clearance exercises. The enrollee has had persistent improvement using Spiriva. The medical necessity and reasonableness, as defined by Medicare rules, of the requested service has not been demonstrated. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.

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-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lenses (V2100, V2103) purchased on October 29,
2020, and November 3, 2020.

You asked the Plan to pay for the lenses. You say that your $150 optical benefit includes lens replacement. You
were reimbursed when you used this provider several years ago, and there is no requirement to purchase
eyewear or lenses at a provider in the Plan's network. The Plan denied your request. The Plan says You did not
purchase the lenses from a plan optical facility as specified in the contract. Therefore, payment cannot be made.

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 up to $150 when they are purchased from a plan optical facility.

We looked at the file and the Plan's rules. The lenses were not purchased at a plan optical facility. Based on this
information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we
decided that the Plan does not have to pay for eyeglass lenses (V2100, V2103) purchased on October 29, 2020,
and November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.

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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on June 1, 2020.

You asked the Plan to pay for the infectious agent detection. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on January 6, 2021.

You asked the Plan to waive the copayment for the specialist visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $40 copayment for each specialist visit for Medicare-covered services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you had a specialist visit on January 6, 2021. You have been asked to pay a $38.29 copayment for the specialist visit, which is less than the contracted $40 copayment amount. The specialist visit falls within the Physicians/Practitioners 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.

Furthermore, you had a surgical procedure on December 23, 2020. This surgical procedure has a 10-day postoperative period. The specialist visit was provided beyond the 10-day period. Therefore, we decided that the Plan does not have to waive the copayment for the specialist visit provided on January 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot manage herself at home. The Plan denied your request. The Plan says the enrollee did not have a decline in function requiring daily skilled services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 physician reviewer found that the enrollee presented to the acute hospital emergency department recently with multiple issues including lower extremity and back pain, hypotension and hyperkalemia. She has been treated in the hospital with emergent dialysis and has been discharged back to home. Reportedly she is presently in her home. No details of any physical therapy or occupational therapy needs are provided in the available records. No details of any acutely unstable medical conditions are provided. The enrollee does not require skilled nursing or therapy services of a qualified professional to effectively provide medically necessary treatment. Daily skilled services are not required on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two retainer crowns and pontic provided on January 6, 2021.
You asked the Plan to pay for the retainer crowns and pontic. You say that you would like $500 worth of these services to be covered. The Plan denied your request. The Plan says these services are not covered.
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 pay for the two retainer crowns and pontic provided on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital admission.

You asked the Plan to pay for the inpatient hospital admission. You say that the enrollee is in pain and the medically necessary procedure needs to be performed in the inpatient setting. The Plan denied your request. The Plan says the enrollee is medically stable, and that the clinical information provided does not demonstrate a need for the procedure to be performed in the inpatient hospital setting.

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 the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee has been approved for a planned elective total left reverse shoulder arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is listed under CPT code 23472 and is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The review has determined that the record does not show that at the admitting physician reasonably expects that the enrollee's necessary hospital care would span 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 the inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist office visit provided on November 4, 2020.

You asked the Plan to waive the co-payment for the specialist office visit. You say that you should not be responsible for the co-payment because the provider was not a doctor, but a physician's assistant. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for each Medicare-covered specialist visit.

You have been asked to pay a $50 co-payment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is considered a specialist practitioner. 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 co-payment for the specialist office visit provided on November 4, 2020.

Your complaint about the provider's capabilities is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 17, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
December 15, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that your previous dentist retired.
You say that you were referred to this dentist. You also say that they needed to do a complete oral evaluation.

The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The
Plan also says that the frequency limit has been exceeded.

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 comprehensive oral evaluation is
listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a
comprehensive oral evaluation that you received on November 14, 2019. Therefore, we decided that the Plan
does not have to pay for the comprehensive oral evaluation (D0150) provided on December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve debridement of benign lesions once every 30 days.
You asked the Plan to pre-approve the debridement once every 30 days. You say that you would like reconsideration because the member has a condition in which calluses grow very quickly so this service is required once every 30 days. The Plan denied your request. The Plan says this service is only covered once every 60 days.
The Plan must follow Medicare rules. Medicare rules say that routine foot care services are considered medically necessary once (1) in 60 days. 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 debridement once every 30 days. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not indicate that more than once every 60 days
service is needed. The local coverage determination excludes more than one visit every 60 days. 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 debridement once every 30 days have not been met. Therefore, we decided that the Plan does not have to pre-approve debridement of benign lesions once every 30 days.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI), any joint of upper extremity (73221).
You asked the Plan to pre-approve an MRI. You say that please see attached. MRI was completed on 06/06/2021. Elbow approved. Shoulder has not been at this time. The Plan denied your request. The Plan says that the record do not support that the enrollee meets the NCD criteria for the requested MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee fell from a flatbed truck on outstretched arm approximately a week prior. Forearm and humerus films were negative. Physical examination shows decreased range of motion and slight step off at acromioclavicular joint. The documentation supports the medical reasonableness and necessity of the requested service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI), any joint of upper extremity (73221).
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: 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 LTACH is the quickest and safest chance for the enrollee to get off the ventilator and would give him an opportunity to go to an acute rehab with the goal of getting him home with the best quality of life. The Plan denied your request. The Plan says the guidelines for coverage have not been met and that the enrollee could safely receive the services needed in another setting.

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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve genicular nerve block. You say that you are in pain, cannot sleep at night,
and can hardly walk. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because this procedure is experimental/investigational.
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 genicular nerve block. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the role of genicular nerve blocks and radiofrequency ablation (RFA) is the subject of
ongoing clinical trials. Therefore, this would be an experimental/investigational procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 8, 2020.

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 billed with an incorrect Place of Service (POS) code.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the proper POS code.

We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed
with POS code 12 for a home setting. 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 office
visit rendered on September 8, 2020.