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

We decided that the Plan does not have to pre-approve lumbar decompression (63047).
You asked the Plan to pre-approve lumbar decompression (63047). You say that the requested lumbar decompression is medically necessary. The Plan denied your request. The Plan says the requested lumbar decompression is not medically necessary.
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 lumbar decompression (63047). Our reviewer says that the requested lumbar decompression is not medically necessary. Our physician reviewer found the enrollee is with lower back pain for the last 6 months. Based on the documentation provided, there is no recent trial and failure of conservative measures. Surgery is not needed at this time. The request is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar decompression (63047) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar decompression (63047).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care from May 31, 2019 through June 2, 2019 provided to the enrollee by an out-of-network provider.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says Health Plan and Medicare rules require the member to obtain covered services from Plan providers except for emergency care and out-of-area urgent care. The Plan states they did not authorize the admission or the cardiology services provided to the member.
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 inpatient hospital care from May 31, 2019 through June 2, 2019 provided to the enrollee by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for walker, folding (pickup), adjustable or fixed height (CPT Code E0135) provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the folding walker. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the folding walker have not been met. Code E0135 is the only code that has been identified at this time that would require use of all three of the above listed modifiers. Providers must report these modifiers on claims for items identified by codes E0135 that is furnished on or after January 1, 2005. In the future, other codes may be identified as codes that must be submitted with these modifiers, and contractor instructions will be prepared to address the implementation of these modifiers for these codes at that time. Therefore, we decided that the Plan does not have to pay for walker, folding (pickup), adjustable or fixed height (CPT Code E0135) provided to the enrollee on June 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One injection (J7325).You asked the Plan to pre-approveSynvisc-One injection (J7325). You say that the requested Synvisc-One (J7325) injection is medically necessary.The Plan denied your request. The Plan says the requested Synvisc-One (J7325) injection is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Synvisc-One injection (J7325). Our reviewer says that the requested Synvisc-One (J7325) injection is not medically necessary. Our physician reviewer found the enrollee is with stabbing pain localized to left groin region, left anterior thigh extending to knee and pain while attempting to climb stairs and weight bearing. The request is for Synvisc-One. Synvisc is experimental to be used in the hip. More research is needed. The request is not medically reasonable or necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One injection (J7325) have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One injection (J7325).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 12, 2019 through August 15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 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 the review has determined that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 12, 2019 through August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by out of network provider.
You asked the Plan to pre-approve an office visit. You say that you were a former patient of the doctor in 2001. The doctor performed computer assisted sinus surgery on you with great results. The doctor advised you that at the time you might need follow up in the future since some of what was removed could grow back. You were a member of Medicare with the facility and were not aware the doctor was not a provider in your Plan. The doctor is contracted with another facility and your request is only "slightly out of network" as you are not asking for coverage from a doctor that is not contracted with the plan at all. The Plan denied your request. The Plan says the doctor is not part of the Medicare Me Provider System. As a member of the plan, you must receive services from providers in the plan Provider System. These providers are identified in the Plan MEDICARE Me Provider Directory we provided to you. You can also find this Directory on the web at www.vivamedicaremember.com.
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 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. 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 an office visit to be provided by out of network provider.
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 requested admission to an IRF is medically necessary. The Plan denied 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 due to exacerbation of heart failure, anemia with melana and acute kidney injury. She was aggressively managed, and stabilized. The enrollee is afebrile currently. The enrollee's blood pressures are now stable and oxygen needs are 2-liters via a nasal cannula. Functionally, she is minimal assist to standby assist for transfers, mobility, and gait x 120 feet. Endurance is fair-poor. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin/O2 care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal/standby assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.
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 for eyeglasses add-on upgrades provided on September 12, 2019.
You asked the Plan to pay for the eyeglasses add-on upgrades. The Plan denied your request. The Plan says eyeglass add-on upgrades are not a Medicare covered benefit.
Medicare rules say eyeglasses upgrades are not a Medicare covered benefit. You can find this information in the Local Coverage Article: Refractive LENSES - Policy Article (A52499).
We looked at the file and the Medicare rules. Medicare says that upgrades are not a covered benefit. Therefore, we decided that the Plan does not have to pay for eyeglasses add-on upgrades provided on September 12, 2019.
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 requested admission to an IRF is medically necessary. The Plan denied 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 has a relevant past medical history that includes Parkinson's disease, diabetes, and rheumatoid arthritis. She has a body mass index of 26. She is currently in the outpatient setting. She lives in a single level residence without steps to the entrance with her 2 daughters. She fell in the beginning of December 2019 and recently became too weak to continue working/driving and has been experiencing increased shaking of her right upper extremity. She had previously been able to function at a modified independent level using a cane with a walker suggested. Currently she is able to perform bed mobility independently. She requires moderate assistance for transfers, ambulating, and basic activities of daily living with minimal assistance required for dressing. The enrollee has a history of Parkinson's disease as described above with a decline in function without new injury as described above. The enrollee's medical conditions appear stable. There are no wound care needs. She is currently in an outpatient setting and does not require any acute hospital level of care. Physician supervision at an acute rehabilitation level of care would not be required. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, there is no new injury or easily reversible impairing condition. She does not require an intensive therapy program. The enrollee is limited by debility and the severity of her neurological condition. There is no reason
to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on September 10, 2019.
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you thought the $400 surgery copayment included the surgeon bill. You say you do not feel that you should pay the $50 copayment. 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 a $50 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the outpatient surgery services. The outpatient surgery services fall within the "Physician/Practitioner services, including doctor's office visits" 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 outpatient surgery services provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external defibrillator provided from August 1, 2019 to September 1, 2019.
You asked the Plan to waive the copayment for the external defibrillator. You say that the insurance did not pay much on this bill and left you with a balance over $1,500. You say that the insurance should have paid more. 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 20% coinsurance for durable medical equipment from an out-of-network durable medical equipment provider. You have been asked to pay $579.90 which is 20% of the allowed amount for the external defibrillator for each date of service. The allowed amount is $2,899.50. ($2,899.50 x 20% = $579.90). ($579.90 + $579.90 = $1,159.80). The external defibrillator falls within the "Durable medical equipment (DME) and related supplies" 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 external defibrillator provided from August 1, 2019 to September 1, 2019.
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 the enrollee meets the LTACH admission criteria. The Plan denied your request. The Plan says the guidelines for coverage of LTACH services have not been met. Additionally, the plan says the enrollee's care can be provided in the current inpatient 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 reviewer says that the enrollee does not meet criteria for coverage of LTACH services. Our physician reviewer found the patient is currently undergoing treatment at an acute care hospital (ACH) for a septic hip and infected kidney stone. The enrollee has undergone orthopedic and urologic procedures. The enrollee continues to receive wound care and a prolonged course of antibiotics. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTCH needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve the blood pressure monitor. You say that you feel that this should be covered because you have diabetes, hypertension and a right ear canal tumor. Your blood pressure needs to be under control before you have surgery or radiation treatment. The Plan denied your request. The Plan says this item is not a covered benefit under Medicare.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis. Records show that you are not on home dialysis. Although a home blood pressure monitor may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item for your condition. Therefore, we decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.
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, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for surgery (15734) provided on June 7, 2019.
You asked the Plan to pay for surgery (15734) provided. You say that you were under anesthesia when the doctors was brought in to assist the surgeon. The Plan denied your request. The Plan says that a notification letter was sent on July 1, 2018 advising that the plan will not pay for any services received from the doctor 15 or more days after the postmark date of the notification letter.
The Plan must follow Medicare rules. Medicare rules say that if the beneficiary did not enter into a private contract with the physician/practitioner and the beneficiary did not receive notice from the A/B MAC (B) that the physician/practitioner opted out of Medicare, then Medicare payment may be made to the beneficiary for the non-emergency and/or non-urgent care services. We confirmed that the provider at issue in this case has opted out of Medicare. However, the record does not show that you received notice that the physician opted out of Medicare. There is no evidence that you have signed a private contract with the opt out provider for the services at issue. Based on this information, we decided that Medicare rules for coverage of surgery (15734) have been met. Therefore, we decided that the Plan has to pay for surgery (15734) that you received on June 7, 2019.