Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your request. The Plan says needs can be safely given 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 in the Medicare rules section.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke and hemiparesis. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the walker purchased on December 1, 2020.
You asked the Plan to reimburse you for the walker purchased from a non-certified supplier. You say that you would like to be reimbursed the amount you would have received had you bought a walker at a Medicare approved facility. The Plan denied your request. The Plan says the provider is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered it must be purchased from a Medicare certified supplier.
We looked at the file and Medicare rules. This supplier is not contracted with Medicare and therefore reimbursement cannot be made. Based on this information, we decided that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not have to reimburse you for the walker purchased on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the thorax (71260) and the bone and/or joint imaging; whole body (78306) provided on February 5, 2021 and
February 12, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $225 copayment for CT scans and for diagnostic radiology other than CT scans.
You have been asked to pay $450 ($225 copayment x 2) for the CT scan and the diagnostic radiology service provided. 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 copayments for the computed tomography (CT) scan of the thorax (71260) and the bone and/or joint imaging; whole body (78306) provided on February 5, 2021 and
February 12, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested services are 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 in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the enrollee does not have documented
skilled nursing nor skilled therapy needs. The enrollee appears unable to participate in skilled therapy. Daily
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of
the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be
provided at a lower level of care (for example: home, assisted living, long-term 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehab with daily physician management. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided 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 in the Medicare rules section. 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.

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 patient was admitted for altered mental status and renal failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested services are 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 in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have documented skilled nursing nor skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs appear to be chronic and custodial. A SNF level of care is not shown to be 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a retinal detachment outpatient procedure of the right eye (67145) provided on April 26, 2019.
You asked the Plan to waive the copayment for an outpatient procedure of the right eye. You say that you were not advised of this cost-share and cannot pay it. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $150 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $150 copayment for an outpatient procedure of the right eye. The EOC confirms $150 is the required copayment for this service. An outpatient procedure of the right eye falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 a retinal detachment outpatient procedure of the right eye (67145) provided on April 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sling operation for stress incontinence for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says no conservative measures have been tried.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found prior to consideration of surgical options for stress urinary incontinence, failure of conservative management should be documented (e.g., bladder neck support prosthesis (pessary); urethral inserts; bladder training; pelvic floor exercise therapy; pharmacotherapy (required if mixed incontinence is present) that should include a minimum of two therapies utilized for at least a 60 day period. The medical records do not indicate that the enrollee has failed conservative treatments. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a sling operation for stress incontinence for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injections.
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary in this case. Our physician reviewer found that based on the
medical records provided, the enrollee has tried and failed Orthovisc, but has not tried and failed Monovisc.
There is no indication that Monovisc would likely be less effective and/or likely have adverse effects for the
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 physician services provided on May 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and suspension sleeve (L2397) provided on November 4, 2020.

You asked the Plan to pay for a knee brace and suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested items are not medically necessary.

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 pay for a knee brace and suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary. Our physician reviewer found that the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee brace have not been met. Furthermore, the suspension sleeve at issue is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and suspension sleeve (L2397) provided on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy (15830).

You asked the Plan to pre-approve these services. You say that you require this surgery as soon as possible. The Plan denied your request. The Plan says that there is no documentation of refractory skin irritation (intertrigo).

The Plan must follow Medicare rules. Medicare rules say that panniculectomy is covered if the LCD 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 requested services are not considered medically reasonable and necessary in this case. You have a large panus and hernia. The record does not indicate that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over three months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of three months. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy (15830).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided on February 19, 2021.
You asked the Plan to pay for treatment of root canal obstruction. You say that you cannot afford to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for treatment of root canal obstruction (D3331) provided on February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology interpretation services provided on March 17, 2021, reported with diagnosis code C23.
You asked the Plan to pay for the surgical pathology services. You say that this was coded correctly, and the diagnosis C23 is supported. The Plan denied your request. The Plan says this diagnosis is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must bill in accordance with the ICD-10-CM guidelines. The guidelines indicate that once a primary neoplasm has been treated, a Z85 code should be used to describe this. Any treatment of a secondary metastasis should be coded as a secondary neoplasm to the new site and used as the primary/first-listed diagnosis on the claim. Code C23 is defined as malignant neoplasm of gallbladder. In this case, the primary cancer of the gallbladder has been resected, and this pathology was done on a metastasis to the colon wall. This means that the primary diagnosis code should be reported as secondary neoplasm of the colon with personal history of gallbladder cancer reported as an additional diagnosis. Based on this information, the diagnosis code reported is not Therefore, we decided that the Plan does not have to pay for the surgical pathology interpretation services provided on March 17, 2021, reported with diagnosis code C23.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten home health skilled nursing visits (G0299).
You asked the Plan to pre-approve ten home health skilled nursing visits. You say that the enrollee is at a high risk of injury and requires home health skilled nursing care. The Plan denied your request. The Plan says the requested services are not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ten home health skilled nursing visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The patient has had extensive prior skilled nursing and should be educated in her disease management at this point. Her needs are not at an ongoing skilled professional nursing level. She has no evidence of new enteral feedings, no evidence of complex wound care or IV antibiotics or other skilled nursing need. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten home health skilled nursing visits (G0299).