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

We decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
You asked the Plan to pre-approve 60 additional routine transportation trips. You say that this is necessary for the enrollee to get to cancer treatments. The Plan denied your request. The Plan says this request exceeds the enrollee's benefit limits.
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 a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the request exceeds the Plan maximum benefit for coverage of routine transportation. The enrollee has
used 22 trips of their yearly benefit and has 38 remaining. Therefore, we decided that the Plan does not have to
pre-approve 60 additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 1,
2021, through March 6, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that the hospital wanted to send her
home to flush and administer the antibiotics, but the sample came back with no infection. You say that they
should not be paid for this claim and you should owe them nothing. The Plan denied your request. The Plan
says the copayment applied 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $295 copayment per day, days 1 to 6, for in-network inpatient hospital care.
The enrollee has been asked to pay a $1,475 copayment for the inpatient stay. ($295/day x 5 days = $1,475).
The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show the enrollee was
admitted as an inpatient for 5 days. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. 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 the
inpatient stay provided from March 1, 2021, through March 6, 2021.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says the records do not support that the enrollee has an illness that is complex enough to require further hospital care, needs to be seen by a doctor every day, or needs special nursing care. 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. Our physician reviewer found the enrollee is receiving acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total hip replacement.

You asked the Plan to pre-approve total hip replacement. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that Medicare will consider Total Hip Arthroplasty (THA) medically reasonable and necessary when specific criteria are 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 total hip replacement. Our reviewer says that the services are not medically necessary. Our physician reviewer found criteria for total hip surgery are not met. A trial of physical therapy is needed for hip pain. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total hip replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve total hip replacement.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2019, through September 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the hospital admission was medically necessary. The Plan denied your request. The Plan says that an observation level of care was approved.
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 medical 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 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 September 12, 2019, through
September 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa.

You asked the Plan to pre-approve Rhopressa. You say that the enrollee is in a severe stage of glaucoma and any elevated eye pressure can affect his vision directly. The appellant says that the enrollee can be blind, mostly in the right eye. The Plan denied your request. The Plan says the requested drug is covered under Part D, and the enrollee does not have Part D coverage under this contract.

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 Rhopressa.

Benefits for Rhopressa 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the continued SNF care. You say that the enrollee was only given 12 days of
physical therapy. You say that the enrollee is weak and not ready to be discharged. The Plan denied your
request. The Plan says the enrollee has reached their highest level of functioning with a skilled program. The
Plan says that the enrollee no longer requires daily skilled services.

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 the continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found as of June 28, 2021, the
enrollee did not require any skilled nursing or rehab services on a daily basis. She was not expected to make
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent
deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish
a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled
services on an inpatient basis, at a SNF level of care as of June 28, 2021. She did not have any parental
medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and
improved; however, her function had plateaued by June 27, 2021, and she did not require any further inpatient
skilled rehab services. The enrollee's function was at or near her prior level of function and she could be
discharged to a lower level of care for further services. As of June 28, 2021, the enrollee required custodial
services. The denial for further inpatient skilled care is upheld.

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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit services (HCPCS G0463) provided to the enrollee on October 15, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a modifier is required with this procedure.
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 G0463 is "Hospital outpatient clinic visit for assessment and management of a patient." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, no modifier was billed. The elements of the coverage rule are not satisfied. The rules state that when a type T or S service is also billed, a modifier must be used. Payment for the requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient clinic visit services (HCPCS G0463) provided to the enrollee on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a P-Stim, electro-acupuncture device (64555).

You asked the Plan to pre-approve a P-Stim device. You say that the enrollee is likely to obtain significant
therapeutic benefit from the neurostimulator treatment. The enrollee has tried and failed conservative care and
medication therapies. The Plan denied your request. The Plan says this item is not covered by Medicare.

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. Based on this information, we decided that Medicare rules for
coverage of a P-Stim device have not been met. Therefore, we decided that the Plan does not have to preapprove
a P-Stim, electro-acupuncture device (64555).
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's illness is not complex enough to require daily physician management and the enrollee does not require specialized nursing services that are only available in an LTACH.
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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the sales tax for the wig purchased on March 4, 2021.
You asked the Plan to reimburse you the sales tax for the wig purchase. You say that you were told the wig was covered with a 20% copay. The Plan denied your request. The Plan says wigs are not covered under your plan however it was determined that you were advised you had coverage for the wig.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. A wig is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Although the Plan is reimbursing you for the wig Medicare does not reimburse separately for sales tax. Therefore, we decided that the Plan does not have to reimburse you the sales tax for the wig purchased on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from March 8, 2019, to March 12, 2019, and billed with DRG 266.
You asked the Plan to pay for inpatient services. You say that this was billed with the correct DRG. The Plan denied your request. The Plan says the records support DRG 267 rather than 266.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 266, endovascular cardiac valve replacement and supplement procedures with major complications or comorbidities. 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 inpatient services. Our reviewer says that the billed DRG is not supported. Our physician reviewer found while the patient had evidence of chronic heart failure (CHF), there was no evidence of an acute decompensation during this admission. As a result, there was insufficient clinical documentation to substantiate acute CHF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from March 8, 2019, to March 12, 2019, and billed with DRG 266.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on August 26,
2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed 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 code.
We looked at the file and the rules. The claim provided shows a place of service as an independent lab. The
records do not show that the enrollee's specimen was obtained at an independent lab. 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 pay for the definitive drug testing services provided on August 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the care provided at a skilled nursing facility (SNF) from May 1, 2020, to June 1, 2020.

You asked the Plan to pay for the SNF care. You say that you believed that prior authorization was not required because the enrollee was diagnosed with COVID-19. The Plan denied your request. The Plan says the criteria for admission to a skilled nursing facility were not met on the dates of service.

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 pay for the SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found based on the documentation provided, there are no identifiable skilled nursing needs or skilled nursing services that were provided during the time of service. This beneficiary did not meet the severity of illness or intensity of service criteria for inpatient care at a skilled nursing facility.

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 care have not been met. Therefore, we decided that the Plan does not have to pay for the care provided at a skilled nursing facility (SNF) from May 1, 2020, to June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.
You asked the Plan to pre-approve the dental extractions. You say that the enrollee presented to your office
with non-restorable teeth and with recurrent infections. You say that the enrollee has a history of head and neck
cancer with radiation treatment. The Plan denied your request. The Plan says dental extractions are not a
covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313),
power seat elevation system (E2300), and electronic connection between wheelchair controller and two or more
power seating system motors (E2311).
You asked the Plan to pre-approve an expandable controller, a harness, power seat elevation system, and
electronic connection between wheelchair controller and two or more power seating system motors. You say
that the services are necessary. The Plan denied your request. The Plan says based on the documentation
provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is medically necessary when
specific criteria are 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 an expandable controller, a harness,
power seat elevation system, and electronic connection between wheelchair controller and two or more power
seating system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer
found the documentation does not reveal that the enrollee requires other types of proportional input devices
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional
input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered
seating actuators through the drive control, a separate display (i.e., for alternate control devices), other
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive
control), or an attendant control. The enrollee's strength in the upper extremities supports that the enrollee can
control any power options through their own individual switches. The E2300 is not medically necessary as it is
not primarily medical in nature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller, a harness, power seat elevation system, and electronic
connection between wheelchair controller and two or more power seating system motors have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness
(E2313), power seat elevation system (E2300), and electronic connection between wheelchair controller and
two or more power seating system motors (E2311).