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

We decided that the Plan does not have to pre-approve an oral nutritional supplement. 
 
You asked the Plan to pre-approve the supplement. You say that this is medically necessary. The Plan denied your request. The Plan says the information received for the appeal did not establish medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve an oral nutritional supplement.
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 was active and that IRF care is needed in order to maintain his ability. The appellant says that the enrollee is a perfect candidate, lives in a home with staircases and would find difficulty in getting to and from his bedroom and bathroom every day. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for IRF care. The Plan says that the enrollee's needs can be safely met in a lower 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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy, but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. There is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2202) and frames (V2020) purchased
July 12, 2019.
You asked the Plan to pay for the vision services. You say that you were not aware this provider could not be
used as you have always filled your prescription there. Their products are much cheaper than elsewhere The
Plan denied your request. The Plan says vision services must be rendered by an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when purchased from a plan optical facility.
We looked at the file and the Plan's rules. Eyewear must be purchased from a plan optical facility. Based on
this information, we decided that the Plan's rules for coverage of the vision services have not been met.
Therefore, we decided that the Plan does not have to pay for progressive lens (V2202) and frames (V2020)
purchased July 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a meal benefit.
You asked the Plan to pre-approve a meal benefit. You say that the hospital is trying their best not to admit you. The Plan denied your request. The Plan says you were not admitted as an inpatient.
Medicare generally does not cover meal services. However, the Plan offers a meal benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. The records do not show that you have been discharged following an inpatient stay. Based on this information, we decided that Plan's rules for coverage of a meal benefit have not been met. Therefore, we decided that the Plan does not have to pre-approve a meal benefit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance transport provided on October 16, 2019.You asked the Plan to waive the coinsurance for the ambulance transport. You say that you were trying to save money but weren't thinking clearly. You say that this will be difficult to pay.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 4% coinsurance, limited to Medicare-covered transportation.You have been asked to pay $15.89, which is 4% of the allowed amount for the ambulance transport. The allowed amount is $397.27 (4% x $397.27 = $15.89). The ambulance transport falls within the "Ambulance services" 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 coinsurance for the ambulance transport provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on January 24, 2020 from a nonparticipating provider. 
 
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits 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 the eyewear purchased on January 24, 2020 from a non-participating provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid purchased on January 17, 2020 from a nonplan
provider.
You asked the Plan to pay for the hearing aid. You say that the provider told you that the plan does not cover
hearing aids. The Plan denied your request. The Plan says they will select the provider or vendor that will
furnish the covered hearing aid.
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.
Review of the file show that you purchased a hearing aid from an out-of-network provider. Your EOC states,
the plan will select the provider or vendor that will furnish the covered hearing aid. 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 the hearing aid purchased on January 17, 2020 from a non-plan provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 17, 2020.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 February 17, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation. You say that additional routine transportation is medically necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
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 30 trips per year. You have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the records provided support
the need for inpatient psychiatric care. The Plan denied your request. The Plan says the clinical information
does not support the level of care in dispute.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric services. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was
admitted to the acute inpatient psychiatric hospitalization on June 19, 2020 with Schizoaffective Disorder
Bipolar Type. Based upon review the records provided it was not expected this enrollee would improve in a
reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and
denied any auditory or visual hallucinations. The enrollee continued to have some episodes of responding to
internal stimuli but was compliant with treatment while not showing any acute threats to safety. It did not
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care
rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or
others but was compliant with her 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 the inpatient psychiatric services have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a hysterectomy.
You asked the Plan to pre-approve a hysterectomy. You say that this is the best way to treat the enrollee's
excessive uterine bleeding. The Plan denied your request. The Plan says that there are other ways to control the
enrollee's bleeding.
The Plan follows Medicare rules. Medicare rules say that payment may be made for sterilization procedures
only where sterilization is a necessary part of the treatment of an illness or injury.
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 a hysterectomy. Our reviewer says that
the requested procedure meets criteria for coverage. Our physician reviewer found a hysterectomy is an
acceptable, medically necessary treatment option for heavy menstrual bleeding. The patient has failed other
medical treatments and has anemia. The patient was counseled regarding her options for treatment and
hysterectomy was the option she elected based on all the risks/benefits/alternatives. The primary indication for
the hysterectomy is clearly the heavy menstrual bleeding, sterilization is not an indication for the surgery.
Therefore, hysterectomy is a necessary part of the treatment of the patient's illness.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a hysterectomy have been met. Therefore, we decided that the Plan has to preapprove
a hysterectomy.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there is no need for intensive and comprehensive therapy.
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 physician reviewer found that you are generally medically stable after spine surgery, with no recent neurological or orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently you are at a moderate to maximum assist level. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 continued inpatient psychiatric hospital services for the
enrollee.
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that these services
are medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee reached
reasonable expectations for improvement and is medically stable.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the
enrollee in this case. Based upon review the records provided it is not expected this enrollee would improve in
a reasonable period of time as she does not have suicidal or homicidal ideation noted and denied any auditory
or visual hallucinations. The enrollee was compliant and not showing any acute threats to safety. It does not
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care
rather than a lower level of care as she did not have dangerousness to self or others but was compliant with her
treatment. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for
inpatient psychiatric hospital services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued inpatient psychiatric hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sphenopalatine ganglion blocks for the enrollee. 
 
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the enrollee's health problem. 
 
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 the blocks. Our reviewer says that the requested blocks are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered experimental and investigational. The role of the sympathetic nervous system in migraine is still not well understood and there are no evidence based guidelines at present that support sympathetic or somatic nerve block. Therefore, the request is considered not medically necessary or reasonable. 
 
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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve sphenopalatine ganglion blocks for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift equipment you received on November 9, 2019.You asked the Plan to pay for the lift chair. The Plan denied your request. The Plan says this provider is does not participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The requested provider is not enrollee in the Medicare program, which means that payment cannot be made to this provider. Based on this information, we decided that Medicare rules for coverage of the lift chair have not been met.Therefore, we decided that the Plan does not have to pay for the seat lift equipment you received on November 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided December 18, 2019 to January 1, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met. 
 
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 pay for the skilled nursing facility (SNF) services provided December 18, 2019 to January 1, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve an intrathecal pump trial. We decided that the Plan does not have to pre-approve hydromorphone.
You asked the Plan to pre-approve an intrathecal pump trial. You say that this is medically necessary. The Plan says that the enrollee has not tried less invasive treatments.
We decided that the Plan has to pre-approve an intrathecal pump trial.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections (ESIs) are covered when there is a documented VAS for pain or NPRS equal to or greater than 3/10 (moderate to severe pain) with functional impairment in activities of daily living (ADLs). 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 an intrathecal pump trial. Our reviewer says that the enrollee has a documented VAS for pain or NPRS equal to or greater than 3/10 (moderate to severe pain) with functional impairment in activities of daily living (ADLs). He has failed multiple other medical therapies and SCS. A trial of intra-thecal medication is medically reasonable and 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 an intrathecal pump trial have been met. Therefore, we decided that the Plan has to pre-approve an intrathecal pump trial.
We also decided that the Plan does not have to pre-approve hydromorphone.
The Plan follows Medicare rules. Medicare rules say that Medicare may cover a drug or biological 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 hydromorphone. Our reviewer says that the use of hydromorphone is off-label while a trial of Duramorph or Ziconontide would be consistent with FDA labeling. Hydromorphone is therefore not medically reasonable and 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 hydromorphone have not been met. Therefore, we decided that the Plan does not have to pre-approve hydromorphone.
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.