Persius/hicric huggingface dataset:
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 IRF care will help the enrollee regain the optimize level of functioning. The Plan denied your request. The Plan says rules for IRF care have not been met.
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. Our physician reviewer found that the patient was admitted for lumbar spine surgery and a urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve five (5) additional PT visits in the home.
You asked the Plan to pre-approve five (5) additional PT visits in the home. You say that you are having a hard time using your leg and it is causing hip problems. The Plan denied your request. The Plan says that an additional five (5) PT visits in the home are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 five (5) additional PT visits in the home. Our reviewer says that the additional physical therapy is medically necessary. Our physician reviewer found that the health Plan argues that after four PT sessions, you can walk 500 feet. Only two PT visits have been submitted for review. What is reported as the fourth visit does not note how far you can walk. The submitted documentation does not yet show a plateau in function or a functional level no longer in need of PT. The health plan has failed to support its argument. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) additional PT visits in the home have been met. Therefore, we decided that the Plan has to pre-approve five (5) additional PT visits in the home.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left sacroiliac joint arthrodesis.
You asked the Plan to pre-approve arthrodesis, open, sacroiliac (SI) joint, including obtaining bone graft, including instrumentation, when performed (27280). You say that you are having low back pain that radiates to the hips, buttocks, and lower extremities. The Plan denied your request. The Plan says medical studies haven't proven that the procedure is helpful for treatment of your condition.
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 arthrodesis, open, sacroiliac (SI) joint, including obtaining bone graft, including instrumentation, when performed (27280). Our reviewer says that the patient has had bilateral SI joint injections which provided her with 60-70% pain relief for the duration of the local anesthetic. Our physician reviewer found the patient does not have an evidence-based indication for an
open SI joint arthrodesis. The request is not medically reasonable or 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 arthrodesis, open, sacroiliac (SI) joint, including obtaining bone graft, including instrumentation, when performed (27280) have not been met. Therefore, we decided that the Plan does not have to pre-approve left sacroiliac joint arthrodesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve onabotulinumtoxinA (Botox) injections, 600 units per treatment, 3 treatments.
You asked the Plan to pre-approve Botox. You say that the request for 600 units per treatment is medically necessary. The Plan denied your request. The Plan says the requested dosage of 600 unites per treatment is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Botox. Our reviewer says that onabotulinumtoxinA injections at 600 units per treatment are not medically necessary. Our physician reviewer found the requested use of onabotulinumtoxinA injections at 600 units per treatment is not FDA-approved for the enrollee's diagnosis. The reviewer found that its use at the requested dose of 600 units per treatment is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the requested dosage is not medically reasonable or 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 Botox have not been met. Specifically, the requested dose is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve onabotulinumtoxinA (Botox) injections, 600 units per treatment, 3 treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic appliance (E0627) and a pneumatic compressor (E0652) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that an in-network provider is available to render the requested items.

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 at issue in this appeal.

We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic appliance (E0627) and a pneumatic compressor (E0652) to be rendered by the out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of soft tissues of head and neck (CPT code 76536) provided to the enrollee on January 14, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the enrollee should have a $45 specialist copayment and a $50 copayment for diagnostic radiology services. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received the ultrasound of soft tissues of head and neck (CPT code 76536) on January 14, 2021. The enrollee was asked to pay a $110 copayment for the ultrasound. Your 2021 EOC states that enrollees must pay a $110 copayment for Medicare-covered diagnostic radiology services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound of soft tissues of head and neck (CPT code 76536) provided to the enrollee on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the injections and medication provided on January 26, 2021, at the outpatient department of an in-network provider.
You asked the Plan to waive the cost-share for the services. You say that the cost for these services are more than they have been in the past. The Plan denied your request. The Plan says their records indicate when you had this procedure in the past, it was rendered in a doctor's office. The Plan states the place of service has an impact on your cost-share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received injections and medication on January 26, 2021, at the outpatient department of an in-network hospital. You were asked to pay a $225 copayment for the outpatient hospital facility visit and 20% coinsurance for the Part B drugs. Your 2021 EOC states that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug for Part B drugs obtained in a provider's office or outpatient setting and a $225 copayment for each in-network Medicare-covered outpatient hospital facility visit. 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 cost-share for the injections and medication provided on January 26, 2021, at the outpatient department of an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Jaco V2 robot arm for a power wheelchair.
You asked the Plan to pre-approve robotic arm. You say that this is medically necessary and could improve your quality of life. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this device attempts to replace - rather than improve- the function of your arm and does not serve a purpose that is primarily medical in nature.
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 pre-approve a Jaco V2 robot arm for a power wheelchair.
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 requires active and ongoing physical and/or occupational therapies and would benefit from an interdisciplinary team and an intensive therapy program. The Plan denied your request. The Plan says an IRF is not medically necessary; the required care can safely be provided in other settings, such as a skilled nursing facility or at home with home health services or outpatient therapies.
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.
Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair accent color.

You asked the Plan to pre-approve power wheelchair black in black accent color (K0108). You say that the
enrollee needs a Group 3 power wheelchair and accessories The Plan denied your request. The Plan says black
in black accent color does not serve a medical purpose.

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 pre-approve the power wheelchair accent color.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from February 25, 2019, through March 1, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia.
You asked the Plan to pay for inpatient services provided from February 25, 2019, through March 1, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia. The Plan denied your request. The Plan says clinically significant hyponatremia that required treatment beyond the correction of the enrollee's hyperglycemia was not present.
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 diagnosis code E87.1, hypo-osmolality and hyponatremia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient services provided from February 25, 2019, through March 1, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the enrollee is a 58-year-old female who presented with shortness of breath. The diagnosis code E87.1, hypo-osmolality and hyponatremia, was included in the notes. Initial testing showed a sodium of 130 and elevated glucose of 509. In this clinical setting, the sodium was low as a direct result of an elevated glucose and after correction, the sodium was 136.5. Technically, this enrollee did not have the requested diagnosis of hypo-osmolality and hyponatremia considering this fact, based on the provided documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from February 25, 2019, through March 1, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 81230, 81231, 81232,
81240, 81241, 81247, 81283, 81291, 81328, 81335, 81350, 81355, 81381, 81407) provided January 7, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or
documented cardiovascular disease.

We looked at the file and Medicare rules. The tests performed were part of a cardiovascular risk panel. This
service is not covered. Based on this information, we decided that Medicare rules for coverage of the lab
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81225,
81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81283, 81291, 81328, 81335, 81350, 81355, 81381, 81407) provided January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac joint injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has bilateral sacroiliitis along with multiple other pain complaints. She has had several prior SI joint injections. The last two have provided 100% pain relief, but the effect only lasted the duration of the local anesthetic. The prior SI joint injections have not provided sustained pain relief. Therefore, the request is considered not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac joint injections.
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 you do not have the ability to stand, and in the past you improved from IRF care. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an implantation of bone conduction hearing device (69710) performed on December 3, 2019.
You asked the Plan to waive the copayment for an implantation of bone conduction hearing device. The Plan denied your request. The Plan says the correct copayment was applied.
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 $360 copayment for surgery services at an outpatient hospital. You have been asked to pay a $360 copayment for an implantation of bone conduction hearing device. An implantation of bone conduction hearing device falls within the "Outpatient surgery, including 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 an implantation of bone conduction hearing device (69710) performed on December 3, 2019.
Your complaint about being billed by the provider for charges beyond the applicable cost-sharing is not a valid appeal for medical coverage. Medicare does not permit us to make a decision about these types of complaints. This part of your complaint is a grievance that must be answered by the Plan. Please note that, according to the case record, the provider has indicated to the Plan an intent to hold you harmless beyond the applicable cost-sharing for services performed on December 3, 2019.