Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services provided from January 27, 2020 to March 6, 2020.
You asked the Plan to pay for eye refraction services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says eye refraction services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear or eye refraction services. The services you asked the Plan to pay for are considered eye refraction services. Therefore, we decided that the Plan does not have to pay for eye refraction services provided from January 27, 2020 to March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the Plan's denial of the requested foot orthotics. You say that you had fractured your femur in multiple locations and now your one leg is shorter than the other. You stated that the requested insert will help to equalize your gait. You say that you believe the requested item is medically necessary for you and therefore it should be covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99071) provided on April 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified.  
 
We looked at the file and Medicare rules. Procedure code 99071 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99071) provided on April 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.
You asked the Plan to pre-approve Prednisone. You say that the enrollee requires this drug for relief of symptoms. The Plan denied your request. The Plan says that the enrollee's medical plan does not cover outpatient prescription drugs.
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 Prednisone.
Benefits for Prednisone 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Epogen.
You asked the Plan to pre-approve Epogen. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Retacrit before it will approve Epogen.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Epogen. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Epogen. Our physician reviewer found the documentation does not show that the enrollee has tried and failed the Plan's preferred drug of Retacrit. The documentation does not show that Retacrit would likely be less effective and/or have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Epogen.
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 disagree with the denial. The Plan denied your request. The Plan says the requested LTACH care is 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 requested LTACH care is not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include respiratory support with tracheostomy care, telemetry, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit on March 10, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that nothing was done during the appointment and the provider should not be paid. 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 $30 copayment per specialist office visit.  
 
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for sinus issues.  
 
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 specialist office visit provided on March 10, 2020.   Your complaint about the long wait times and the poor service by the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility admission. 
 
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 that the enrollee does not require the intensity of services provided at an inpatient rehabilitation facility. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the specialist treated your sister and you feel comfortable with them. The Plan denied your request. The Plan says you can get medically needed care from a doctor in your primary 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are no skilled nursing needs identified. 
 
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 the requested services. Our physician reviewer found that you have a history of stroke. You were referred to home health to improve walking skills, as you are ambulatory for short distances with a device. You demonstrate impaired muscle strength and overall mobility. There is no indication you are home-confined. As such, the necessity for home health care services is not substantiated. Therefore, this request is 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core build up, and periodontal scaling.
You asked the Plan to pre-approve the requested services. You say that the enrollee's tooth is causing severe pain. The Plan denied your request. The Plan says the requested services are not covered.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core build up, and periodontal scaling.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient chemical dependency treatment. 
 
 
You asked the Plan to pre-approve outpatient chemical dependency treatment. You say that this treatment is essential to the enrollee's continued sobriety. The Plan denied your request. The Plan says the requested facility is not a covered inpatient hospital or outpatient hospital setting. 
 
The Plan follows Medicare rules. Medicare rules say that outpatient treatment of alcoholism is covered only when it is reasonable and necessary per the guidelines listed 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 outpatient chemical dependency treatment. Our reviewer says that the criteria for coverage of the requested services has not been met. Our physician reviewer found the facility does not meet the qualifications of an inpatient hospital setting for medical necessity for alcohol detoxification and rehabilitation or outpatient alcohol detoxification and rehabilitation. Documentation does not show that the center is considered a intoxication/rehabilitation program and therefore does not meet the criteria as outlined by Medicare for the services of alcohol detoxification. Based on the information provided in the record, this program does not meet the Medicare criteria as an inpatient or outpatient hospital setting for the detoxification or rehabilitation of alcohol treatment, there is no documentation of current issues or medical necessity for this treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient chemical dependency treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient chemical dependency treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device supplies to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve CPAP supplies. You say that the CPAP machine was approved however the additional requested supplies were not. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because this provider is out-of-network with the Plan and these supplies can be obtained from an in-network provider. 
 
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 continuous positive airway pressure (CPAP) device supplies to be provided by an out of network (OON) 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 IRF admission is reasonable and necessary. The Plan denied your request. The Plan says your needs can be met at an alternative level of care. 
 
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at an alternative 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: 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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 20, 2020 with acute on chronic respiratory failure. He walked 60 feet with a front wheeled walker on June 29, 2020 and his oxygen saturation dropped to 89 percent. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support he would be able to fully participate in and benefit from an intensive therapy program 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on December 4, 2019.
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of 76700-26, which was approved and previously paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the abdominal ultrasound have not been met. Specifically, the record indicates that the Plan has approved and paid for an abdominal ultrasound rendered on this date of service. The documentation submitted does not support an additional unit of this service. Therefore, we decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 5, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you feel like this was incorrectly denied. The Plan denied your request. The Plan says no prior authorization was obtained, 
 
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 lab work provided on December 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. You say that you have lost hearing function. The Plan denied your request. The Plan says hyperbaric oxygen therapy for sudden hearing loss has not been found to be medically reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is 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 Medicare guidelines does not support the diagnosis of sudden idiopathic hearing loss of the ear. Without the support of the guidelines, the requested services are not considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.