Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (CPT 99053) provided to the enrollee on March 8, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service is already included in the approved emergency department services.
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 99053 is "Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found Common Procedural Terminology (CPT) 99053:Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service, is not separately billable. 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 pay for emergency services (CPT 99053) provided to the enrollee on March 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a UroLift implant. 
 
You asked the Plan to pre-approve a UroLift implant. You say that the enrollee has failed several void trails as 
well as Flomax and Finasteride. The Plan denied your request. The Plan says the enrollee's prostate volume is 
documented to be 158cc. The Plan says that FDA guideline contraindications indicate that the UroLift System 
should not be used if the enrollee has prostate volume of more than 100cc. 
 
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 a UroLift implant. Our reviewer says 
that a UroLift implant is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the United States Food and Drug Administration (FDA) has approved the use of the 
UroLift system to treat prostates up to 100 mL. This information has not been included in the current AUS 
guidelines yet, which state that prostate glands up to 80 mL in size may be treated with UroLift. The medical 
records indicate that the enrollee has a prostate gland that is too large (158 mL) to qualify for UroLift. 
 
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 UroLift implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a UroLift implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee may be appropriate for an alternate level of care, such as SNF or outpatient 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication 
management, skin and diabetic care, and daily therapy can be provided at a SNF. A less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An 
IRF intensity is not warranted. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says your condition can be managed in a skilled nursing facility. 
 
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 you were medically stable after an UTI with no evidence of need for supervision by 
acute PMR or acute rehab nursing care. You may benefit from further PT and OT but do not require an 
intensive therapy program. You are at CGA/SBA functionally and do not require 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the blood serum eye drops purchased on February 
19, 2020. 
 
You asked the Plan to reimburse you for the blood serum eye drops. You say that autologous serum eye drops 
are helping your condition. The Plan denied your request. The Plan says autologous serum tears are not 
considered medically reasonable and necessary. 
 
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 reimburse you for the blood serum eye 
drops purchased on February 19, 2020.  
 
Benefits for the blood serum eye drops 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851).
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that knee orthosis defined by L1851 is covered if the beneficiary has recent injury to or surgical procedure on the knee or when there is documented knee instability. The record sent by your physical therapy provider indicates that you have knee pain but your records do not demonstrate recent injury or surgery or that instability of your knee was found on physical exam by your physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 18, 2019 to October 17, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the service was not medically necessary.
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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 18, 2019 to October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Xolair (J2357) injection every 14 days. 
 
You asked the Plan to pre-approve the Xolair. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the requested use of this drug exceeds the 
maximum allowed dose for the member's indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only 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 the Xolair. Our reviewer says that the 
use of Xolair (J2357) 300 mg subcutaneous injection every 14 days for treatment of chronic urticaria is not 
indicated, not supported and not recommended in any of the compendia. Our physician reviewer found the 
requested use of Xolair is not FDA-approved for the member's condition. 
 
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 Xolair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Xolair (J2357) injection every 14 days.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the documentation
provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. The enrollee appears to be at his new baseline following a stroke two
months ago. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that patients in inpatient psychiatric care may be 
discharged by stepping down to a less intensive level of outpatient care when certain criteria is 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 inpatient psychiatric admission. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of July 17, 2020 forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations 
and was not showing any behaviors. The enrollee was being cooperative and compliant while not showing any 
symptoms of withdrawal. 
 
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 admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the riboflavin ophthalmic solution (J2787) 
provided on June 9, 2020. 
 
You asked the Plan to waive the coinsurance for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance was applied 
correctly to the service provided. 
 
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 20% 
coinsurance of the plan-allowed amount for Medicare-covered Part B drugs administered by an in-network 
provider.  
 
You have been asked to pay $587.10 ($2, 935.50 plan allowed amount x 20% coinsurance) for the Medicare-
covered Part B drug administered by an in-network provider. 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 riboflavin ophthalmic solution (J2787) provided on June 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with chronic 
obstructive pulmonary disease (COPD), diabetes, coronary artery disease (CAD) and hypertension who was 
admitted to acute care on 8/13/20 for weakness and increasing back pain. From a nursing perspective, the 
enrollee received oral medications. The enrollee had stable vital signs. He had a foley catheter. He was treated 
for pyelonephritis. Regarding rehabilitation services, the enrollee received physical therapy and occupational 
therapy in the acute hospital. The enrollee was at a moderate assist with bed mobility and required a 
mechanical lift for transfers and he remained non-ambulatory. The enrollee required varying assist with 
activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on November 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on November 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that MRI of the right knee is needed to further evaluate
the pain and swelling that the enrollee is experiencing. The Plan denied your request. The Plan says clinical
information provided did not show new or changed musculoskeletal signs and/or symptoms when results of a
plain x-ray taken after the current episode of symptoms started or changed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the
requested MRI is not medically necessary. Our physician reviewer found the documentation does not include
plain x-rays. Our physician reviewer found that the documentation provided does not support that the requested
MRI is appropriate.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Reader.
You asked the Plan to pre-approve a Freestyle Libre 14 Day Reader. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 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 a Freestyle Libre 14 Day Reader. Our reviewer says that the item is not medically necessary. Our physician reviewer found we would need to know the medications you take for diabetes mellitus and if you are checking blood glucose levels now with a meter and what the medical rationale is for needing the CGM. Without this data, we cannot say if the CGM meets medical necessity criteria. 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 Freestyle Libre 14 Day Reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Reader.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (J1200, 99283, 
J7030, 96374) provided September 8, 2019. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you received poor 
service and the copayment should be waived. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room services. the emergency room services 
fall within the Emergency 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 for 
emergency room services (J1200, 99283, J7030, 96374) provided September 8, 2019.