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

We decided that the Plan does not have to waive the coinsurance and copayment for diagnostic testing, outpatient hospital surgery services and prescription drugs provided on January 3, 2020, January 21, 2020 February 14, 2020.
You asked the Plan to waive the coinsurance and copayment for diagnostic testing, outpatient hospital surgery services and prescription drugs. You say that these services did not help you so you should not have to pay coinsurance. The Plan denied your request. The Plan says you were charged the 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 a $400 copayment for outpatient surgery and 20% coinsurance for Medicare Part B prescription drugs and diagnostic tests. You have been asked to pay a $400 copayment and 20% coinsurance for Medicare Part B prescription drugs and diagnostic tests. 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 and copayment for diagnostic testing, outpatient hospital surgery services and prescription drugs provided on January 3, 2020, January 21, 2020 February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diabetic shoes and inserts
You asked the Plan to pre-approve diabetic shoes and inserts. You say that the claim should be paid. The Plan
denied your request. The Plan says the documentation does not meet Medicare coverage criteria, there was not
an in-person visit within six months prior to the delivery of the shoes/inserts.
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 diabetic shoes and inserts. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not indicate that the patient had an examination with a
certifying physician within six months of the order or met with a supplier for an in-person evaluation prior to
receiving diabetic shoes. The patient does have diabetic polyneuropathy with a foot callus which is a covered
condition. The criteria for the requested A5500 and A5512 have not been met per LCD L33369 and local
coverage article A5250.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of diabetic shoes and inserts have not been met. Therefore, we decided that the
Plan does not have to pre-approve the diabetic shoes and inserts
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic manipulation (98940) therapeutic exercises (97110) and mechanical traction (97012) provided June 12, 2020 to July 1, 2020.You asked the Plan to pay forthe chiropractic services. You say that when you received the bills you contacted your insurance company and they informed you that you must write a letter to appeal the claims.The Plan denied your request. The Plan says this request exceeds the benefit limit of 12 visits per year.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.The plan offers additional chiropractic benefits that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The health plan contract says that 12routinechiropractic visits are covered each year. The records show that the plan has covered for 12 chiropracticvisits. Therefore, the benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forchiropractic manipulation (98940) therapeutic exercises (97110) and mechanical traction (97012) provided June 12, 2020 to July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the unspecified oral surgery procedure
(D7999) provided on June 2, 2020.
You asked the Plan to pay the in network rate for the unspecified oral surgery procedure. You say that your
previous dentist has retired. You say that you were recommended a dentist near your home as you are
concerned about traveling long distances due to Covid-19. You say that due to your poor hearing and the
dentist wearing a mask, you did not hear what they said about your coverage. The Plan denied your request.
The Plan says the unspecified oral surgery procedure is not listed as a covered service.
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 pay the in
network rate for the unspecified oral surgery procedure (D7999) provided on June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMems device (CPT Codes: C2624 and 33289).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental/investigational in the treatment of heart failure.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered experimental or investigational. 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 pre-approve the CardioMems device (CPT Codes: C2624 and 33289).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe extraction of erupted tooth and deep sedation/general anesthesia services (D7210, D9222, D9223) provided on June 1, 2020.You asked the Plan to pay forthe extraction of erupted tooth and deep sedation/general anesthesia services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says that they did not render a decision within the allotted timeframe.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. The Plan covers the extraction of erupted tooth and deep sedation/general anesthesia services.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extraction of erupted tooth and deep sedation/general anesthesia services have been met.Specifically, the services at issue are covered by the Plan's supplemental dental benefit and were provided by an in-network providerTherefore, we decided that the Plan has to pay forthe extraction of erupted tooth and deep sedation/general anesthesia services (D7210, D9222, D9223) provided on June 1, 2020.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the admission is not medically necessary.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 these services. Our reviewer saysthat daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to an inpatient rehabilitation facility (IRF) on November 2, 2020. You are currently walking with a walker and need assistance for bed mobility and transfers. You have no skilled nursing needs. You have no skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility or home with home health services.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies provided from March 24, 2020, to March 29, 2020.
You asked the Plan to pay for the infusion supplies. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says the documentation does not support the billing for these supplies.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The proof of deliver must include delivery confirmation and the DOS must either reflect the date shipped or the date received. The record does not contain a valid proof of delivery for the supplies provided in this case. The billed date of service begins on March 24, 2020, which does not match either the shipped or received dates of these supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided from March 24, 2020, to March 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe urology services provided on August 24, 2020 by an out of network provider.You asked the Plan to pay forthe urology services. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide the services at issue in this appeal. 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 forthe urology services provided on August 24, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda.You asked the Plan to pre-approveKeytruda. You say that the requested Keytruda is medically necessary.The Plan denied your request. The Plan says the requested Keytruda is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is diagnosed with advanced stage II squamous cell carcinoma of the lung. The requested use of Keytruda for the enrollee's diagnosis is not FDA-approved for single-agent treatment of metastatic NSCLC in patients with tumors with PD-L1 expression (TPS =1%), as determined by an approved test, and with disease progression on or following platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression (on approved EGFR-or ALK-directed therapy) prior to receiving pembrolizumab. This enrollee has no driver mutations documented or PD-L1 status.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 the medical records provided the complexity of the patient's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy
program. Based on the medical records provided there is no documentation that the patient requires the
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled
nursing facility level appears to be more appropriate in this case.
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 1, 2020, to
February 6, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says
that inpatient 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 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 from February 1, 2020, to February 6, 2020.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from June 9, 2020 to July 3, 2020.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says a RAP claim was not billed.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that a RAP claim was not billed for these services.Therefore, we decided that the Plan does not have to pay forthe homehealth services provided to the enrollee from June 9, 2020 to July 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 19, 2020, through August 20, 2020.

You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary for the enrollee. The Plan denied your request. The Plan says the inpatient hospital care provided 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee did need rate control and did need intravenous medications. However, this was not a new diagnosis and she was already on oral anti-coagulation. The enrollee did not require the admission and could have been placed in observation and admitted if she did not respond to the initial therapy.


We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 19, 2020, through August 20, 2020.
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 medical needs are being met in the current acute
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 enrollee
still requires acute hospital level of care services and 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. There are no services available at the LTACH that the enrollee requires
that are not available at the health care setting being offered by the health plan. 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.