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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 pay for lumbar-sacral orthosis (L0650) provided to the enrollee on May 21, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
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 orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. The medical records in the case file do not note any back complaints, and there is no documented physical examination of the back. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on May 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and extraction provided on August 31, 2015.
You asked the Plan to pay for the first intraoral periapical x-ray and extraction. The Plan denied your request. The Plan says these services are not covered benefits under Medicare and the Plan.
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 for the first intraoral periapical x-ray and extraction provided on August 31, 2015.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 6, 2019.You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not advised prior to your dental services that this dentist had opted out of seeing Medicare enrollees.The Plan denied your request. The Plan says this dentist has opted-out of participating in Medicare programs.The Plan must follow Medicare rules. The rules say thatno Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by this provider.  This provider has opted out of the Medicare program. The file shows that this provider, entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on August 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs to be in the SNF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the information provided demonstrates that there are no additional services at the requested facility that aren't available where the enrollee is now.
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 was admitted to a SNF after acute care admission for a urinary tract infection, confusion, and weakness. The enrollee's prior level of function was living alone in a home with 2 steps to enter. She was independent with ambulating with a walker and independent with activities of daily living. The enrollee's current level of function is ambulating 200 feet then 350 feet with a wheeled walker with standby/contact guard assist, negotiating 5 stairs with contact guard assist, and sit to stand with contact guard assist. The records do not support that the enrollee needs continued daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing physical therapy and occupational therapy, the records do not support the need for daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on July 26, 2019 from a non-contracted provider.
You asked the Plan to pay for the hearing aids. You say that you assumed there would be some type of reimbursement for the items. The Plan denied your request. The Plan says Hearing Care Solution informed the plan that you canceled an order on July 21, 2019 because you did not want to undergo a credit check for financing. The Plan states you purchased the hearing aids from a non-contracted provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. You purchased hearing aids from a provider that is non contract provider. Your EOC clearly states, coverage for hearing aids is limited. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on July 26, 2019 from a non-contracted provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 1, 2019 to August 16, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you were not aware of the cost share and the provider should have told you when you were released. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $0 copayment for each day for days 1-20 and a $160 copayment each day for days 21-45. You have been asked to pay a total of $2,080 for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) Care" benefit category. See chart below.
Dates of Service
Service
Copayment per Day
SNF Days
Number of Days
Member Liability
July 14, 2019 to July 31, 2019
SNF care
$0
1-18
18
$0
August 1, 2019 to August 2, 2019
SNF care
$0
19-20
2
$0
August 3, 2019 to August 16, 2019
SNF care
$160
21-33
13
$2,080
Total
$2,080
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 SNF stay provided from August 1, 2019 to August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable


 We decided that the Plan does not have to pay for an office visit (99213), and a diagnostic laryngoscopy (31575) provided on September 26, 2019 by out of network provider. 
 
You asked the Plan to pay for an office visit, and a diagnostic laryngoscopy. You say that you have a physician as your throat doctor. You received a letter saying he was not one of your providers. You did not know that and you will continue seeing him. You are requesting the Plan to take care of the bill and let you know what your copay will be. You need to know about another plan so you can get your doctor on a provider list. The Plan denied your request. The Plan says while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. 
 
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 an office visit (99213), and a diagnostic laryngoscopy (31575) provided on September 26, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIMFINZI (J9173).You asked the Plan to pre-approveIMFINZI (J9173). You say that the requested IMFINZI is medically necessary.The Plan denied your request. The Plan says the requested IMFINZI 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 IMFINZI (J9173). Our reviewer says that the requested IMFINZI is not medically necessary. Our physician reviewer found the enrollee is with stage IV T3N3M1b squamous cell lung cancer with brain metastasis. The requested IMFINZI is only used for treatment of unresectable stage III non-small cell lung cancer which has not progressed following concurrent platinum-based chemotherapyand radiation therapy. The requested IMFINZI is not medically necessary in the enrollee's 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 IMFINZI (J9173) have not been met.Therefore, we decided that the Plan does not have to pre-approveIMFINZI (J9173).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223, 99233) provided from June 23, 2019 to
June 26, 2019.
You asked the Plan to pay for hospital care. You say that these services were not related to hospice. The Plan
denied your request. The Plan says payment for these services is the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on June 22, 2019. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care (99223,
99233) provided from June 23, 2019 to June 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthroplasty services (27447) performed by a surgical assistant on January 14, 2019.
You asked the Plan to pay for surgical assistant services. You say that these services were performed by a Certified Surgical First Assistant who is capable of performing assistant surgery services. The Plan denied your request. The Plan says surgical assistants are not recognized for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for arthroplasty services (27447) performed by a surgical assistant on January 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 14, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.
You asked the Plan to pre-approve additional transportation. You say that transportation will improve the enrollee's ability to be successful on dialysis. The Plan denied your request. The Plan says the enrollee has zero remaining trips for the calendar year.
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 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 24 trips this year. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the cochlear device (L8614) and cochlear device implantation (69930).You asked the Plan to pre-approve the cochlear device and cochlear device implantation. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 indenying the request to pre-approve the cochlear device and cochlear device implantation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee meets all of the criteria. His difficulty with phonation due to previous vocal cord injury should not affect his ability to hear with a cochlear implant and undergo rehabilitation. His ENT and audiologist have determined that he will be able to undergo the extensive rehabilitation required after cochlear implantation. According to national guidelines and FDA guidelines, hoarseness is not a contraindication to placing a cochlear implant.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 cochlear device and cochlear device implantation have been met.Therefore, we decided that the Plan has to pre-approvethe cochlear device (L8614) and cochlear device implantation (69930)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has been in the hospital with a urinary and skin infection and is too weak to go home. You say that the enrollee used to be able to walk and do laundry, but is now not able to do normal routines or walk. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that the enrollee could receive the needed care in another setting.
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 from and participate in additional physical and occupational therapy, but 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on July 12, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 providethe 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 forphysician services provided to the enrollee on July 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plandenied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/22/20 who is now status post 4 vessel coronary artery bypass graft (CABG). The enrollee was discharged to SNF on 1/30/20 where she currently remains. The enrollee's prior level of function includes living alone in a 1 story home with 3 steps to enter. The enrollee was independent with activities of daily living.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 physical therapy and occupational therapy 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-approveacute inpatient rehabilitation facility (IRF) admission and services.