Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveinsertion of a chest wall respiratory sensor (Inspire procedure).You asked the Plan to pre-approveInspire procedure. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the Inspire procedure is considered to be experimental and/or investigational.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Inspire procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there are several studies that have looked at hypoglossal nerve stimulation as a way to improve upper airway stimulation and thereby treat the enrollee's condition. Based on the high-quality evidence published across different specialties, the hypoglossal nerve stimulator should not be considered experimental or investigational. There is long-term data that shows a reduction in the severity of obstructive sleep apnea, good patient compliance, a reduction in sleepiness, and improvement in quality of life.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Inspire procedure have been met.Therefore, we decided that the Plan has to pre-approveinsertion of a chest wall respiratory sensor (Inspire procedure).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is not safe to be discharged home.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. Therules 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 indenying 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 records do not indicate that there are significant or complex medical/nursing issues that could not be addressed at the Skilled Nursing Facility (SNF) level of care. Ongoing medication management, wound care, and daily therapy can be provided at an SNF. In this case, the enrollee is mostly moderate to maximum assistance for functional transfers and activities of daily living, so a less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit from or participate in an IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveButrans 5mcg/hr patch for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication falls under Part D coverage.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 Plandoes not haveto pre-approveButrans 5mcg/hr patch for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
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 considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the acute care hospital is able to provide all of the services the enrollee requires. Based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to "the doctor", an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansayscare must be received from a 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 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 Plandoes not haveto pre-approvea referral to "the doctor", an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for supplement mitral valve with synthetic substitute, percutaneous approach (02UG3JZ) provided from July 16, 2019 to July 18, 2019.You asked the Plan to pay forsupplement mitral valve with synthetic substitute, percutaneous approach. You say that you would like reconsideration based on the medical records provided.The Plan denied your request. The Plan says an invalid Clinical Trial number was submitted on the claim.The Plan must follow Medicare rules. Effective for claims with dates of service on or after January 1, 2014, it is mandatory to report a clinical trial number on claims for items/services provided in clinicaltrials/studies/registries, or under Coverage with Evidence Development.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of supplement mitral valve with synthetic substitute, percutaneous approach have not been met.Specifically, the record shows that a claim was billed with Clinical Trial Number 02033811. This Clinical Trial Number is not listed on the Medicare website as an approved Clinical Trial for the service at issue. Therefore, we decided that the Plan does not have to pay forsupplement mitral valve with synthetic substitute, percutaneous approach (02UG3JZ) provided from July 16, 2019 to July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approve IRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysalternate settings can be requested and reviewed.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 documentation does not reveal updated documentation that post surgery the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal updated post 1/15/20 notes that reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PTand OT but the documentation does not reveal updated notes after the 1/15/20 that reveals that the enrollee requires therapy on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee's medical complexity does not require daily physician oversight.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 skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services)on a "daily basis". As a practical matter this enrollee does not require the necessary services on 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 IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.You asked the Plan to pre-approve a lumbar epidural steroid injection. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are covered for the above 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 a lumbar epidural steroid injection. Our reviewer says that a lumbar epiduralsteroid injection is not medically reasonable and necessary. Our physician reviewer found that the progress notes do not contain fundamental physical exam findings such as sensory, motor, reflex or range of motion testing. There is no recent imaging of her spine. The lack of fundamental required documentation mandates that this request be deemed 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 a lumbar epidural steroid injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea lumbar epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.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 considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the acute care hospital is able to provide all of the services the enrollee requires. Based on the provided medical records the patient is receiving necessary services and is at an appropriate level of care in the acute care hospital. Her prognosis appears to be poor. Continued care at the currentlevel is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveseven units of neuropsychological testing.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plandenied your request. The Plan says five units of testing are approved but seven further are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that neuropsychological testing is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary.Our physician reviewer found the enrollee has short-term memory loss versus pseudo-dementia. The plan has approved five units/hours of testing and denied an additional seven units/hours. The requested testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain. The enrollee's difficulties have been mild; therefore, the requested additional units are not reasonable or medically necessary at this time.We looked at thisphysician's review, the file, and Medicare rules. 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 pre-approveseven units of neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you require the stockings for lymphedema.The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered under the surgical benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncoveredbecause they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe meningococcal vaccine you received on September 16, 2019.You asked the Plan to pay forthe meningococcal vaccine. The Plan denied your request. The Plan says this is not a covered service.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the meningococcal vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the meningococcal vaccine.Therefore, we decided that the Plan does not have to pay forthe meningococcal vaccine you received on September 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the emergency care you received on August 6, 2019.You asked the Plan to waivethe copayment. You say that you were misdiagnosed.The Plan denied your request. The Plan says you are responsible for the copaymentThe 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 $120 copayment for emergency care. Review of the file shows that you were provided emergency care on August 6, 2019. You have been asked to pay a $120 copayment for the services. The services fall within the emergency care benefit category. This means thatyou 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 waivethe copaymentfor the emergency care you received on August 6, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing forthe mammogram servicesto 20% coinsurance.You asked the Plan to waive the cost-sharing forthe mammogram. You say that you should have no responsibility for these services.The Plan says that the diagnostic mammogram was billed appropriately based on findings in accordance with Medicare rules.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The rules also say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient diagnostic tests.You have been asked to pay $163.99 in cost-sharing for mammogram services of which totaled an Allowed Amount of $156.34. You are being asked to pay more than the Allowed Amount of these services. 
The Explanation of Benefits(EOB)within the record does not adequately show why you are being chargedthis amount. You are being charged more than 20% coinsurance. While it appears some servicechargesmay have applied to your deductible, the record does not provide documentationto show that you had not met your deductible prior to the service at issue (such as EOBs from prior months) and does not explain why you are being charged more than the Allowed Amount for these services. The Plan application of cost-sharing and processing of this claim cannot be substantiated based on the documentation provided. Therefore, we decided that the Planhas to reduce your cost-share to 20% coinsurance for these services. We also decided that the Plandoes not have to waivethe cost-sharing forthis service entirely(to $0).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approveneurology visits. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network neurologist.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 networkprovider 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-approvethe medical services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysneeds can be safely met at 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating more than 100 feet. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.