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

We decided that the Plan has to pay for the acute inpatient hospital care provided July 5, 2019 to July 6, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care
provided was medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital
care was 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 the 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 review has determined that the enrollee presented to the Emergency
Department (ED) after multiple syncopal episodes. On evaluation he had slurred speech and elevated
laboratory results. The ED physician suspected metabolic/toxic encephalopathy. He was initially treated with
IV fluids, IV thiamine, IV insulin and Vitamin K. He was then admitted to the intensive care unit (ICU). The
enrollee was evaluated by Nephrology and his mental status was monitored. His condition stabilized and
improved, and he was at baseline the following day. He was stable enough to be discharged the following day
with outpatient follow-up. His dramatic improvement allowed an earlier than anticipated discharge given his
presentation. The review has determined 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 the acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided July 5, 2019 to July 6, 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 waive the copayment for inpatient hospital care from July 22, 2019 through July 25, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. 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 shows that you were admitted on July 22, 2019 and discharged on July 25, 2019. You were asked to pay a $370 copayment per day from July 22, 2019 through July 24, 2019, days 1-3 of your inpatient hospital care. You were discharged on July 25, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5. 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 inpatient hospital care from July 22, 2019 through July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee has reached his baseline, and he is no longer a danger to himself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued services. Our physician reviewer found that active treatment was not taking place beyond the date in question. The services were not reasonably expected or medically necessary to improve the enrollee's condition, or for the purpose of diagnosis. There was no individualized treatment plan, however the entire record is not present. Based upon review the records, the enrollee does not require an acute inpatient mental health treatment for March 19, 2020 forward, as he was not showing any suicidal or homicidal ideation and was not showing any behaviors or aggression being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric health services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage (80 miles for a one-way trip).
You asked the Plan to pre-approve additional routine transportation mileage. You say that you have no other way to get to your doctor's appointment. The Plan denied your request. The Plan says the benefit limit for routine transportation is 50 miles per one-way trip.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to a benefit limit of 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The request exceeds the Plan benefit limits. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage (80 miles for a one-way trip).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for decompression fasciotomy (25020) provided on October 3, 2019.
You asked the Plan to pay for the decompression fasciotomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the operative report did not include documentation of decompression fasciotomy of the forearm and/or wrist, flexor OR extensor compartment, without debridement of nonviable muscle and/or nerve; therefore this code cannot be verified.
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 25020 is decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve. We asked our coder 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 decompression fasciotomy. Our reviewer says that CPT code 25020 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve, therefore, this service cannot be validated. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the decompression fasciotomy have not been met. Therefore, we decided that the Plan does not have to pay for decompression fasciotomy (25020) provided on October 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana 100mg tablet.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says oral medications are considered self-administered drugs.
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 Invokana 100mg tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit.
You asked the Plan to pre-approve the TENS unit. You say that the records provided support the need for a TENS device. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that coverage for TENS units used to treat chronic low back pain is limited to cases in which the beneficiary is enrolled in an approved clinical study. We looked at the file and Medicare rules. The records show that the TENS device is being requested for treatment of chronic lower back pain. The records do not show that you are enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the scooter lift purchased on September 21, 2019.
You asked the Plan to reimburse for the scooter lift. You say that you received reimbursement from the Plan
for your fully automatic scooter and were wondering if the Plan would make payment on your scooter lift as
well. The Plan denied your request. The Plan says this equipment does not service a medical purpose.
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 reimburse for the scooter lift purchased on September 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveInvokana 100mg tablets.You asked the Planto pre-approvethe Invokana tablets. You say that the enrollee needs this medication due to his diabetes and chronic kidney disease.The Plandenied your request. The Plansaysthis oral drug is not covered by Medicare Part B.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 Plandoes not haveto pre-approveInvokana 100mg tablets.Benefits for the Invokana tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza cap 24mcg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under the enrollee's plan under any normal circumstances.
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 Amitiza cap 24mcg for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a drug that you take orally.
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 Pregabalin for the enrollee.
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 this is medically necessary.The Plan denied your request. The Plan says supervision three times a week from a rehab doctor is not required.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 enrollee'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.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on September 12, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says that these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on September 12, 2018 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says requesting this on top of the home and portable oxygen equipment that are already being used is not considered reasonable and necessary.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you already have a home system and a portable system. a home system and a portable system serves the same purpose as the concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee will benefit from short-term rehabilitation.The Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF coverage.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral nutrition and medications. The enrollee had stable vital signs. The enrollee had a wound vac and wound care changed three times per week. He also had tracheostomy and Foley catheter care. The enrollee did not receive physical therapy or occupational therapy in the acute hospital and is dependent for mobility and activities of daily living. Our physician reviewer found that there were no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs, but they are not required on a daily basis. The enrollee does not meet the 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injections for the enrollee.
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations is covered when the above 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 pre-approve Orthovisc. Our reviewer says that Orthovisc injections are not medically reasonable and necessary for the enrollee in this case. The documentation does not clearly reveal that the patient has failed at least three months of conservative therapy. It is not clear that the patient has failed medication management. Per the 2/5/20 progress note she has no side effects from medications and state they continue to decrease her pain and increase her overall activity level and allow her to provide self ADLs and engage in some of her listed goals. There is no evidence that the patient failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy. There is no evidence that other diagnoses have been excluded by appropriate evaluation and management services, laboratory and imaging studies. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Orthovisc.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (99601) provided on October 26, 2019 through November 1, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status code of I which is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99601 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, CPT code 99601 has a status code of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on October 26, 2019 through November 1, 2019.