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

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.

You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your request. The Plan says the records show that the same study or a test like it has been done for the enrollee. The Plan states the records also show the results of this test and the prior study showed the enrollee's doctor what they needed to see in order to the enrollee's condition. The Plan states repeat imaging is not supported without results of prior imaging that show a clear reason for it.

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 PET scan. Our physician reviewer found the review indicates that the enrollee does not meet medical necessity requirements for a combination PET/CT scan. The requirements are: 
1. Elevation of blood tests associated with recurrent cancer without abnormal findings on imaging; or 
2. Distinct cancer lesions have spread from the original sight and the member is a candidate for aggressive surgical resection or other localized treatment to metastasis to cure the cancer; or 
3. To determine if there is tumor recurrence or post-radiation scarring. The enrollee had a recent CT scan which showed the lung lesions have increased in size. The review has determined that the medical records provided do not meet the requirements listed in the NCD for Medicare 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 the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can be safely met with home health services at home with supervision or from home health services in an assisted living facility.

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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.

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 skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urological procedure/sacral nerve stimulation.

You asked the Plan to pre-approve urological procedure/sacral nerve stimulation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is only covered for certain indications.

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 urological procedure/sacral nerve stimulation. Our reviewer says that the documentation does not support Our physician reviewer found the enrollee has urinary frequency, urgency, urge incontinence and sensation of incomplete emptying. The enrollee has failed ditropan, detrol, and myrbetriq. The enrollee has not had any behavioral or surgical therapy. The enrollee has not had at least a 50% improvement with a test stimulation trial. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of urological procedure/sacral nerve stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve urological procedure/sacral nerve stimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts.

You asked the Plan to pre-approve foot inserts. 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.

The records do not show that you 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 inserts.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a SNF admission.

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 care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient's needs can be met in the current facility. He has no complex wound care. The patient and caregivers can be educated on tube feeding management in the current IRF and this does not require a transfer to a SNF. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing and skilled therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting. The patient's needs can be met currently in the inpatient rehabilitation facility with a plan to transition to the home or community 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive this care 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. The patient received treatment at an acute care hospital (ACH) for post-COVID pneumonia and acute-on-chronic respiratory failure in the setting of advanced pulmonary sarcoidosis and pulmonary hypertension. At the time of transfer to the LTACH, the enrollee was not intubated/ventilated. There is no evidence that the enrollee required services that were not available at the ACH. As LTACHs and ACHs are licensed to provide the same level of care, there was no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the colonoscopy you had at an outpatient hospital facility.

You asked the Plan to reduce the copayment for the colonoscopy. You say that you believe you should only have to pay the $275 copayment for ambulatory surgical center services instead of the $350 copayment for outpatient hospital facilities. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the copayment is based on the place of service and how the facility is designated in your Provider Directory. In this case, the facility where you had this procedure is designated as an outpatient hospital facility in your Provider directory.

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 $350 copayment for outpatient surgery in an outpatient hospital facility. 

You have been asked to pay a $350 copayment for the colonoscopy. The facility where you had this procedure is not designated as a standalone ambulatory surgery center in your Provider Directory. Therefore, the colonoscopy falls within the outpatient surgery in an outpatient hospital facility 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 reduce the copayment for the colonoscopy you had at an outpatient hospital facility.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound.

You asked the Plan to waive the copayment for the ultrasound. You say that during this visit, you only had a diagnostic mammogram, so you don't understand why you were charged two $40 copayments. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you did not only have a diagnostic mammogram on this date--the Plan says that you also had a breast ultrasound. That is why you were charged two separate $40 copayments for this date of service.

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 basic imaging services including x-rays and ultrasounds.

You have been asked to pay a $40 copayment for the ultrasound in addition to the copayment for the diagnostic mammogram. The medical records show that you had both services. 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 the ultrasound.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0425 and A0428) provided on November 10, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you would like reconsideration because you believe the balance should be the responsibility of the hospital as you were told this service would be covered. The Plan denied your request. The Plan says the member's EOC states there us a $250 copayment for ambulance services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for 

The enrollee has been asked to pay a $242.45 copayment for the ambulance services. This means that the enrollee has been asked to pay an amount less than the $250 copayment. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services (A0425 and A0428) provided on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been treated with observation 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room with complaints of bilateral leg pain, weakness, shortness of breath, chest numbness, tingling, and weight loss. Her symptoms had been worsening for 2 weeks. She also reported a recent fall. The member reported having bilateral numbness of her feet for a year, with worsening of numbness and tingling for months. On exam she had an unsteady posture when standing up and could not walk without assistance. She was evaluated and treated until she was safely discharged. The review indicates that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient'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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care attendant services.
You asked the Plan to pre-approve the requested services. You say that you need help with household cleaning.
The Plan denied your request. The Plan says the requested services are not covered.
The Plan must follow Medicare rules. The rules say that custodial care is not covered.
We looked at the file, and Medicare rules. The requested household cleaning services are considered custodial
care. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we
decided that the Plan does not have to pre-approve personal care attendant services.
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
require the intensity of acute level of rehabilitation.

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 the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
weakness and congestive heart failure. Your medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by a non-contracted provider.

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 services were rendered by a non-contracted provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided by a non-contracted provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by an OON provider.

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 services were rendered by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The referring provider is not a
network provider with the Plan. The Plan had network providers available who could have provided the
items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does
not have to pay for the laboratory services provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nebulizer you rented.

You asked the Plan to waive the coinsurance for the nebulizer. You say that you were not told what the rental costs would be or that any coinsurance would apply. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

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 20% coinsurance for durable medical equipment.

You have been asked to pay 20% coinsurance for the nebulizer. The nebulizer falls within the durable medical equipment 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 coinsurance for the nebulizer you rented.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extraction you received on November 27, 2019.
You asked the Plan to pay for the extraction. The Plan denied your request. The Plan says the benefit limit was reached.
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 services are subject to a benefit limitation. The Plan covers dental services up to $1,000 per calendar year. The records show that the $1,000 benefit limit was reached with the processing of this claim. You are responsible for any amount in excess of the benefit limit. Therefore, we decided that the Plan does not have to pay for the dental extraction you received on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the provider failed to request prior authorization before rendering services.

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 physician's services. 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 physician's services.