Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator.You asked the Plan to pre-approvea home ventilator. The Plan denied your request. The Plan says that the recordsdo not show that you have ongoing breathing failure (chronic respiratory failure) with a high carbon dioxide level in your blood, while you are awake and in a stable state.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary. Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. You are noted to have chronic respiratory failure in the setting of morbid obesity. There is no evidence that you have a neuromuscular disease. You have had several recent hospitalizations, during which you responded quickly to supplemental oxygen and/or non-invasive ventilation. There is no evidence that you have been intolerant or non-responsive to home BiPAP/CPAP.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator.
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 needs further care. 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee underwent surgical repair for a femur fracture on April 21, 2020 and is bearing weight on the leg, as tolerated. He needs assistance with dressing, grooming, and transfers. The complexity of his nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require 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 neuromuscular junction testing (95937) provided on October 1, 2019.You asked the Plan to pay for neuromuscular junction testing. You say that these services were requested by an in-network surgeon.The Plan denied your request. The Plan says this code was inappropriately used to report train of four testing.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.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 neuromuscular junction testing. Our reviewer says that CPT 95937 is not supported by the records. Our physician reviewer found the medical records provided do not include documentation of neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method being performed on October 1, 2019. The medical records indicate that Train of Four testing was performed. Train of Four testing does not meet the definition describing CPT code 95937, therefore it is inappropriate to bill CPT code 95937 for the services performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing have not been met.Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on October 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided on December 18, 2019.You asked the Plan to waive the copayment forphysical therapy. You say that there was no mention of costs or copayments. You say that you were under the impression that insurance covered it.The Plan denied your request. The Plan says the copayment 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 a $40 copayment for each in-network, Medicare-covered therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation 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 copayment forphysical therapy provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe pathology services provided on January 9, 2020.You asked the Plan to waive the copayment forthe pathology services. You say that you never had to pay for laboratory services when you had a different insurance plan. You say you cannot afford this copayment every time you have blood drawn. 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. for Medicare-covered lab services and diagnostic procedures/tests performed in an outpatient hospital facility. You have been asked to pay a $30 copayment for the pathology services. The pathology services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe pathology services provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that a cardiology evaluation is needed before surgery. The Plan denied your request. The Plan says the exam can be done with an in-network provider, and the request is not urgent and does not require emergency attention.
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 a referral to an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to hold the member harmless for physical therapy services provided on November 1, 2018 through November 29, 2018.You asked the Plan to hold the member harmless for the physical therapy services. You say that you would like reconsideration because billing errors should not be the member's responsibility.The Plan denied your request. The Plan says that the member did not have significant pain so physical therapy was not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for the physical therapy services by the provider. The provider is a contract provider. The file does not show that the plan provided notice that the physical therapy services would not be covered. Under Medicare rules, this means the physical therapy services is considered approved by the plan.Therefore, we decided that the Plan has to hold the member harmless for physical therapy services provided on November 1, 2018 through November 29, 2018.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Hydroxychloroquine 200mg tab.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare does not cover drugs that are usually self-administered.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 Hydroxychloroquine 200mg tab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair power seat elevation feature.
The enrollee asked the Plan to pay for the power seat elevation feature (E2300). The enrollee said that the power seat elevation feature allows more independence in cleaning the home and repositioning. The Plan denied the request. The Plan says a power seat elevation feature does not serve a primary medical purpose and cannot be covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature (E2300) have not been met. Therefore, we decided that the Plan does not have to pay for the power wheelchair power seat elevation feature.
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 you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Prednisone is not covered under the Medicare Part B benefit for the enrollee's condition.The Plan must follow Medicare rules. The rules saythat 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 Trihexyphenidyl 2mg tablets.You asked the Plan to pre-approve Trihexyphenidyl. You say that the drug is medically necessary.The Plan denied your request. The Plan says the medication is not eligible for coverage under the Part B medical benefit.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 Trihexyphenidyl 2mg tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Trigger Point Injections to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe injections. You say that the service is medically necessary.The Plan denied your request. The Plan says there are network providers that can provide the service at issue.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat 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 thePlan. 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 Trigger Point Injections 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 waive the copayment foran inpatient hospital stay provided from September 28, 2019 to October 1, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges because you suffered from a perforated colon after a colonoscopy.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct 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 $300 copayment each day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from September 28, 2019 to October 1, 2019. Therefore, you are responsible to pay a $300 copayment for days 1-3 (September 28, 2019 to September 30, 2019). $300 (copayment) x 3 (inpatient days) = $900.You have been asked to pay the total copayment amount of$900 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 foran inpatient hospital stay provided from September 28, 2019 to October 1, 2019
Appeal type: Drugs
Decision: Unfavorable

e decided that the Plandoes not haveto pre-approveImuran tab 50mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe drug 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-approveImuran tab 50mg for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says unless otherwise indicated, the criteria requires that the pain is from arthritis in the spine joints, and not from a pinched nerve and/or from nerve irritation.
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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple other pain generators, and therefore does not meet the LCD criteria. The requested block 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on November 20, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were referred to this provider. The Plan denied your request. The Plan says you were referred to this provider.
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. The provider is not in-network and your EOC clearly states, you must go to a participating dental services professional for all covered dental services. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on November 20, 2019 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee was discharged, as he is at his baseline, and no longer needs skilled services.
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 pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you are covered for up to 20 one-way trips per calendar year. The Plan says you have used 18 out of your 20 allotted trips for the 2020 benefit year and no additional trips will be provided.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 20 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. The file shows you have used 18 one-way trips. The Plan benefit allows 20 one-way trips per calendar year. This means, you have two more one-way trips and you will have exhausted the Plan's transportation benefit for 2020.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower limb prosthetic services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve lower limb prosthetic services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are in-network suppliers available to you that can provide the services you are requesting. 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 lower limb prosthetic services to be provided by an out of network (OON) provider.