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

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on February 1, 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 submitted records do not support the billing of code 95816.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95816 is electroencephalogram (EEG); including recording awake and drowsy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the submitted records do not support the billing of code 95816. Our physician reviewer found the records show that the EEG does not appear to have lasted at least 20-40 minutes. The act of closing one's eyes during the performance of an EEG is not the equivalent of having an EEG performed while drowsy (95816), asleep (95819) or in a coma (95822). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on February 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Namenda for the enrollee.
You asked the Plan to pre-approve Namenda. The Plan denied your request. The Plan says Namenda to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Namenda for the enrollee.
Benefits for Namenda 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided to enrollee by an out-of-network provider.You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says the enrollee's needs can be met by network providers.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided to enrollee by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Supartz FX. You asked the Plan to pre-approve Supartz FX. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for Supartz FX is correct, because the enrollee has not had an adequate trial of conservative therapy and the Plan requires a trial of Orthovisc and Monovisc before it will approve Supartz FX.
The Plan follows Medicare rules. Medicare rules say that injections of Supartz FX are only covered by Medicare when the enrollee meets certain specific medical criteria. 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 Supartz FX. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Supartz FX. Our physician reviewer found while it is documented that the enrollee has tried non-steroidal anti-inflammatory drugs (NSAIDs), pain medications, heat and ice therapy, and home therapy with no relief, it is not documented that the enrollee has had a trial of at least 3 months of conservative therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin tag removal from the back.
You asked the Plan to pre-approve the removal. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered cosmetic.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the removal. Our reviewer says that the requested removal is not considered medically reasonable and necessary in this case. Our physician reviewer found removal of skin tags from the back is not medically reasonable and necessary, as they do not represent any medical significance. 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 removal have not been met. Therefore, we decided that the Plan does not have to pre-approve skin tag removal from the back.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe lens feature (CPT Code V2702) purchased on September 19, 2019.
You asked the Plan to pay for the deluxe lens feature. You say that you should get your full eyeglass allowance of $175 because you purchased standard frames and lenses. The Plan denied your request. The Plan says they processed the claim towards your eyewear benefit. The Plan reimbursed you the Medicare allowed amount for standard lenses and frames, and denied the enhancement feature you received on your lenses.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the deluxe lens feature have not been met. It has been determined that you received a transition feature on your lenses, (CPT code V2702), which is a non-covered Medicare enhancement for your eyewear
benefit. Per your 2019 EOC, Chapter 4, Page 76, it states; In addition to your cost share responsibility, you pay for any additional costs above Medicare allowed payment rates for upgraded lenses, frames or any other enhancements. Therefore, we decided that the Plan does not have to pay for deluxe lens feature (CPT Code V2702) purchased on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that if the enrollee goes home at a lower level of care, she is at risk for a fall, or re-admission to an acute hospital for medical complications. The Plan denied your request. The Plan says it is expected that all medical issues will be stable before leaving the hospital.
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 the enrollee's 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 the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF at this time given her weight-bearing restrictions. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 enrollee has had a complicated
inpatient stay, and meets criteria for this admission. The Plan denied your request. The Plan says all services
that would be provided in the LTACH are being provided already in the current acute care setting already
approved.
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 ACH following a small bowel
resection. The enrollee was intubated/ventilated and eventually received a tracheotomy. He has been tolerating
being on a tracheotomy collar during the day and using a PMV. 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 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-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the orthotics because you have foot pain and it limits the types of shoes you can wear. 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 waive the coinsurance for inpatient hospital care from September 2, 2019 through September 11, 2019 provided by an out-of-network provider.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received inpatient hospital care from September 2, 2019 through September 11, 2019 provided by an out-of-network provider. You are asked to pay 50% coinsurance for inpatient hospital care. 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 coinsurance for inpatient hospital care from September 2, 2019 through September 11, 2019 provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 23, 2019 through August 14, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 23, 2019 through August 14, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee uses the Contour Next test strips. The Plan denied your request. The Plan says you did not submit information that using a preferred brand of test strips would lead to an adverse medical outcome for the enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation showing medical necessity for the non-preferred brand of test strips. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Please note, the Plan has approved 3 months of the Contour Next test strips, with no refill, for the enrollee's transition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT Code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. 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 DME have not been met. Healthcare Common Procedural Coding System (HCPCS) code E0651 NU (1 Unit) remains not supported. The submitted medical records include a delivery sheet, however indicates incorrect patient name. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedural Coding System (HCPCS) code E0667 NU RT (1 Unit) remains not supported. The submitted medical records include a delivery sheet, however indicates incorrect patient name. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedural Coding System (HCPCS) code E0667 NU LT (1 Unit) remains not supported. The submitted medical records include a delivery sheet, however indicates incorrect patient name. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been me Therefore, we decided that the Plan does not have to pay for pneumatic compressor, segmental home model without calibrated gradient pressure (CPT Code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) provided to the enrollee on September 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says care can be received in another setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 an LTACH has the ability to treat the enrollee safely with a nursing ration of 4 to 1, 24-hour respiratory therapy, and daily physician visits. You say that the enrollee cannot be safely managed at a lower level of care. The Plan denied your request. The Plan says LTACH services are not medically reasonable and necessary. The Plan says that, based on the enrollee's current needs, the enrollee should remain in the current acute care 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia, respiratory failure and renal failure. The enrollee required intubation/ventilation, but has since been extubated and is no longer on a ventilator. The enrollee remains dependent for mobility and activities of daily living. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the additional copayments charged for multiple x-rays provided on August 24, 2019.
You asked the Plan to waive these copayments. You say that you were not told there would be more than one copayment. The Plan denied your request. The Plan says you had multiple x-rays taken on the same date of service and each service requires a copayment.
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 $15 copayment for each Medicare covered x-ray. 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 additional copayments charged for multiple x-rays provided on August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for water circulating cold pad with pump (CPT Code E0218) provided to the enrollee on October 1, 2019.
You asked the Plan to pay for the item. You say that the claim should be paid. 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 item have not been met. The rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pay for water circulating cold pad with pump (CPT Code E0218) provided to the enrollee on October 1, 2019.