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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care will provide the enrollee the best chance to regain maximum strength. The Plan denied your request. The Plan says the enrollee's care needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require IRF level of care. The documentation does not reveal that the patient requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical and occupational therapies, but the patient does not require this at IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit package for a power wheelchair.
You asked the Plan to pre-approve a transit package. The Plan denied your request. The Plan says that this is for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit package for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device.
You asked the Plan to pre-approve the a Vertiflex interspinous and/or interlaminar device. You say that the clinical and diagnostic data supports the medical necessity of the requested service. The Plan denied your request. The Plan says medical studies have not proven that the requested device is helpful for treatment of the enrollee's health condition.
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 a Vertiflex interspinous and/or interlaminar device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is considered experimental and more research is needed. 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 a Vertiflex interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG analysis report provided on August 13, 2019.
You asked the Plan to waive the copayment for an ECG analysis report. You say that you think you are being billed incorrectly. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for physician/practitioner services/specialist care services. You have been asked to pay a $25 copayment for an ECG analysis report. Since physician services were provided during an analysis report the correct copayment has been applied. An ECG analysis report falls within the physician/practitioner services/specialist care 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 waive the copayment for an ECG analysis report provided on August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered to the enrollee on April 25, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the testing is non-covered. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the testing rendered to the enrollee on April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 25, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be provided out-of-area.
You asked the Plan to pre-approve the out-of-area MRI services. You say that the enrollee is currently living almost 400 miles away from the city, in order to be with family. You say that the enrollee has been wandering outside of the home and was recently found and taken to the Emergency room. You say that the emergency room physician recommended a neurology consultation, as there is concern the enrollee may have something more going on that is contributing to her worsening memory changes over the past year. The Plan denied your request. The Plan says there are in-network facilities that are able to provide the MRI services needed. The plan says that the requested MRI is not urgent or emergent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 out-of-area MRI services. Our reviewer says that the criteria for coverage of out-of-area care have not been met. Our physician reviewer found the need for the treatment in dispute was not unforeseen prior to leaving the service area. Per the neurology consult notes provided for review, the enrollee is noted to have had memory impairments for the preceding 2 years. Changes were noted to be gradual in nature.
In this time-frame the requested imaging study could have been ordered at an earlier period in the enrollee's cognitive change/decline rather than at this time. At this point the impression from the neurology consult was of a progressive dementia syndrome. There were no findings on exam (or in the enrollee's history) that would warrant/necessitate emergent/urgent intervention in this enrollee's case/care. There were no findings to strongly suggest a structural pathology that would necessitate immediate intervention. In as much, the requested imaging study could be delayed without medical consequence for the 6 months the enrollee is allowed to reside out-of-area while being covered under the Plan contract type she has. 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 out-of-area MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be provided out-of-area.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided April 30, 2019 to June 5, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient level of care was medically necessary. The Plan denied your request. The Plan says that continued care could have been provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was felt stable for discharge on June 5, 2019. The enrollee had a history of a muscle disorder which was progressing to paraplegia. The enrollee was initially admitted from a skilled nursing facility for a tracheostomy exchange. She tolerated tube feedings. The plan was to discharge the enrollee on June 5, 2019 once final recommendation from the Pulmonologist had been received. 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 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 April 30, 2019 to June 5, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary for the enrollee. The Plan
denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on review of available records, the enrollee does not meet criteria for coverage
for an IRF admission. He prior used a rolling walker possibly since the stroke in 2011. The enrollee is generally
medically stable, with no recent, medical, neurological or orthopedic events and there is no evidence of
complex medical issues that require monitoring by an inpatient PMR physician three times per week or need
for acute rehab nursing care. There is no evidence of need for an intensive therapy program with therapy 3
hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.
Based on review of the available records, the enrollee does not meet CMS criteria for coverage for an
admission to an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and
services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy techniques (97140) provided January 23,
2019 to August 28, 2019.
You asked the Plan to pay for manual therapy techniques. You say that the services provided were medically
necessary. The Plan denied your request. The Plan says there were insufficient documents to corroborate the
billed services.
The Plan follows Medicare rules. The rules say for Medicare to consider coverage and payment for any item or
service, the information submitted by the supplier or provider must corroborate the documentation in the
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
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 manual therapy techniques. Our reviewer
says that the billed code is not supported by the medical records provided. Our physician reviewer found the
medical record does not clearly describe your condition before, during and after the therapy episode to support
that that she significantly benefitted from ongoing therapy services and that the progress was sustainable and of
practical value. In the absence of these required documents, it is not clear that these services are 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 manual therapy techniques have not been met. Therefore, we decided that the
Plan does not have to pay for manual therapy techniques (97140) provided January 23, 2019 to August 28,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair ramp.
You asked the Plan to pre-approve wheelchair ramp. You say that the ramp is needed for the home entrance
due to high risk of falling due to low vision and neuropathy. The Plan denied your request. The Plan says this
item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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) for the enrollee to be provided by an out-of-network provider.
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 enrollee does not have out-of-network benefits.
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 care that cannot be provided by network providers. 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. There is no evidence except for the opinion of the manufacturer that these pumps (E0651) are superior to the in-network alternative. There is no documentation in the medical record that uses any objective data to support a clinical rationale that this pump is the only E0651 option available. We conclude that the in-network DME supplier offers a PCD that will meet the member's needs. If the member were to have an extended trial of the in-network E0651 and it were to fail, future consideration of an out of network exception would be made. Therefore, we decided that the Plan does not have to pre-approve 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) for the enrollee to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 CFR ?422.101.
The rules state that equipment which the enrollee owns or is a capped rental item may be replaced in cases of
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire,
flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to
reaffirm the medical necessity of the item.
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful
lifetime of the equipment. If the item of equipment has been in continuous use by the enrollee on either a rental
or purchase basis for the equipment's useful lifetime, the enrollee may elect to obtain a new piece of
equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is
needed to reaffirm the medical necessity of the item.
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the
absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of
equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the
equipment is delivered to the enrollee, not the age of the equipment. Replacement due to wear is not covered
during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does
cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment
owned by the enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section
110.2 for Repairs, Maintenance, Replacement, and Delivery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on August 8, 2019.
You asked the Plan to pay for a colonoscopy. You say that this practice is the only location that your physicians provide services. The Plan denied your request. The Plan says out of area services must be urgent/emergent.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a colonoscopy have not been met. Specifically, there is no indication that this service was urgent or emergent in nature. Therefore, we decided that the Plan does not have to pay for a colonoscopy provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis (L1851) provided to the enrollee on August 13, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis (L1851) provided to the enrollee on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee's treating physician has diagnosed the enrollee's need for the requested incontinence supplies. You say that the enrollee has needed these supplies for several months. You stated that the need for the requested items is increasing as is the cost. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fitness benefit.
You asked the Plan to pre-approve a fitness benefit. You say that you go to the gym to maintain your heart health. The Plan denied your request. The Plan says that there is no coverage for the fitness benefit in 2020.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve a fitness benefit.