Persius/hicric huggingface dataset:
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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says
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 medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is undergoing a planned total knee arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the current hospital.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital with intracranial hemorrhage, subarachnoid hemorrhage, and subdural hemorrhages. He developed acute respiratory failure and required mechanical ventilation support. Later he had a trach. Currently he is able to tolerate trach collar with oxygen supplementation and is still receiving NG tube feeds. He appears to be more stable, however, he requires additional short-term acute care services, which can be safely be provided at the current acute care facility. He does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from March 20, 2020 to March 26, 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 the plan recommends a change from DRG 689 to DRG 690.
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 689. 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 a eview of the flowsheet on March 25, 2020 noted that the patient remained disoriented even though the physician documentation stated that encephalopathy had resolved. A review of the medical record found no evidence of a significant improvement in mental status with treatment of the UTI to justify the coding of encephalopathy. Therefore, there was insufficient clinical evidence to validate the diagnosis. The review has determined that the records did not support the use of DRG 689. 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 hospital services provided to the enrollee from March 20, 2020 to March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain fused to noble metal crown (D2752) provided for tooth #9 on February 4, 2021.

You asked the Plan to pay for the crown. You say that you have comprehensive dental coverage, so this service should be covered. The Plan denied your request. The Plan says the crown on tooth #9 does not meet the criteria for medical necessity.

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 crown when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. Medical records and x-rays were requested from the provider, however only chart notes were provided. The required x-rays were not submitted for review. Based on the information provided, we cannot determine that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan does not have to pay for the porcelain fused to noble metal crown (D2752) provided for tooth #9 on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultations and treatment to be provided by an
OON provider.

You asked the Plan to pre-approve the consultations and treatment. You say that you want to stay with the
surgeon that knows your case. The Plan denied your request. The Plan says the provider is out-of-network.

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. Therefore, we decided that the Plan does not have to pre-approve
consultations and treatment to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin graft provided on October 14, 2020.

You asked the Plan to waive the copayment for the skin graft. You say that you had skin cancer but your face is a mess where it was removed. 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). Your contract with the Plan clearly says that you must pay a $20 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $20 copayment for the skin graft. The skin graft falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 the skin graft provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for MTHFR genetic testing provided on November 20, 2020.
You asked the Plan to pay for MTHFR testing. You say that the enrollee clearly met the criteria for this testing.
The Plan denied your request. The Plan says this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that MTHFR genetic testing is not covered by
Medicare.
We looked at the file and Medicare rules. This testing is not covered by Medicare. Based on this information,
we decided that Medicare rules for coverage of MTHFR testing have not been met. Therefore, we decided that
the Plan does not have to pay for MTHFR genetic testing provided on November 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga.

You asked the Plan to pre-approve Farxiga. You say that this medication is medically necessary. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.

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 Farxiga.

Benefits for Farxiga 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an exercise bike purchased by the enrollee October 27, 2020.

You asked the Plan to pay for the exercise bike. You say that your provider recommended the stationary bike for daily use. The Plan denied your request. The Plan says the item is not covered because it does not qualify as durable medical or surgical equipment.

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 pay for an exercise bike purchased by the enrollee October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not
require transfer to 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. Our
physician reviewer found based on the provided documentation the patient appears to require additional shortterm
acute care services to receive IV heparin which can safely be administered at the current facility until oral
anticoagulation is started and IV heparin is no longer needed. The patient does not require services at the
LTACH that are not already available and being received at the current facility. There are no services at the
LTACH that the patient requires that are not already available and covered at the current facility. Therefore,
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may
be considered when treatment has completed and he is more stable.

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 LTACH services.
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 these services are medically necessary. The Plan denied your request. The Plan says that this request exceeds the member's needs.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar sacral orthosis (L0651) provided to the enrollee on January 22, 2021.

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 there was no proof of delivery submitted in the documentation.

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 record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The medical records do not show that the enrollee was examined for the back brace. 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 a lumbar sacral orthosis (L0651) provided to the enrollee on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a patient home visit (99350) provided on October 26, 2020, by an out of network (OON) provider.
You asked the Plan to pay for a patient home visit. You say that services have been deemed payable. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a patient home visit (99350) provided on October 26, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services (99308) provided January 4, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says that the plan was unable to make a coverage determination in the allotted timeframe.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the plan's denial letter did not detail the reason for the denial. The plan did not cite any CMS policy to support the denial. Insufficient records were provided by the plan to the IRE to support the plan's denial. Therefore, we decided that the Plan has to pay for physician services (99308) provided January 4, 2021.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that you lose strength and your legs weaken and you are afraid that you will fall. The Plan denied your request. The Plan says you do not meet criteria for the requested item.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that your condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Pneumatic Compression Device (E0667, E0651).

You asked the Plan to pre-approve the Pneumatic Compression Device. You say that the device is medically
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Pneumatic Compression Devices are only covered
when medically necessary.

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 Pneumatic Compression Device.
Our reviewer says that the requested device is medically necessary. Our physician reviewer found based on the
medical records provided and the General Coverage Criteria there is documentation that the requested
pneumatic compression device meets Medicare criteria for medical necessity. Records document the patient's
diagnosis, prognosis, symptoms and objective findings, including measurements which establish the severity of
the condition and the reason the device is required, including the treatments which have been tried and failed.

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 Pneumatic Compression Device have been met. Therefore, we decided that
the Plan has to pre-approve a Pneumatic Compression Device (E0667, E0651).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Eliquis 5 mg tablet.
You asked the Plan to pre-approve Eliquis tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Eliquis 5 mg tablet.
Benefits for Eliquis tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.