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

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says this is 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 pre-approve a home ventilator. Our reviewer says that a home ventilator is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was recently hospitalized with acute hypercarbic and hypoxic respiratory failure. The enrollee improved on BiPAP in the hospital. The enrollee is morbidly obese. A diagnosis of COPD is listed, but not confirmed on pulmonary function testing (restriction, no obstruction). OHS appears to be the primary diagnosis, with hypoventilation perhaps worsened by chronic narcotic use for pain. Medicare does not cover ventilators for the treatment of OHS, or for use as a BiPAP device. Current guideline for treatment of patients hospitalized with exacerbation of OHS is BiPAP, with an outpatient sleep study and PAP titration as soon as possible. There is no evidence for failure of BiPAP when stable, as an outpatient. A home ventilator is not medically 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of Freestyle Lite Test Strips.
You asked the Plan to pre-approve continued use of Freestyle Lite Test Strips. You say that the enrollee has been using Freestyle Lite Test Strips and refuses to use any other brand. You say that the enrollee does not need to use the brand Freestyle for any medical needs and the enrollee is requesting the brand Freestyle out of preference. The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file shows that the treating physician states that the requested non-preferred brand, Freestyle Lite Test Strips, are not medically needed and the enrollee is requesting this non-preferred brand out of preference. Therefore, we decided that the Plan does not have to pre-approve continued use of Freestyle Lite Test Strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 23, 2019 to August 23, 2019 by the out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 23, 2019 to August 23, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a SNF facility. The Plan denied your request. The Plan says the enrollee has not been successfully weaned from the vent.
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care with ventilator support and weaning, nebulizer treatments, neurologic monitoring, surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you are unable to walk without assistance.The Plan denied your request. The Plan says there are no medical issues that would require supervision by an inpatient rehab physician.The Plan must follow Medicare rules. The rules say thatIRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that your current level of function is contact guard assist with standing, ambulating 200 feet with contact guard assist, contact guard assist with bed mobility, minimal assist with sit to stand, and transferring with minimal assist. You are currently medically stable, and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the laboratory work provided on September 4, 2019.
You asked the Plan to reduce the copayment for the laboratory work. You say that your laboratory bills are usually $3.60 or $8.00. 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 $40 copayment for in-network Medicare-covered lab services. You have been asked to pay a $40 copayment for the laboratory work. The laboratory work falls 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 reduce the copayment for the laboratory work provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle (POV) (three or four wheel non-highway) specify brand name and model number (CPT Code E1230), for the enrollee.
You asked the Plan to pre-approve the POV. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. The enrollee can ambulate within his home with the use of an assistive device (rollator walker) and can perform his MRADL's. Therefore, we decided that the Plan does not have to pre-approve power operated vehicle (POV) (three or four wheel non-highway) specify brand name and model number (CPT Code E1230), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 28, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were informed there was no copayment. You say that you do not owe the provider. 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 $30 copayment for in-network Medicare covered specialist services. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a dermatologist, which is considered a specialist. 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 the office visit provided on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this 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 Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry rendered to the enrollee on May 14, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. The rules say that the PC for diagnostic services must be billed with modifier -26. We looked at the file and Medicare rules. The provider did not bill code 88344 with modifier -26 to allow for separate payment of the PC. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry rendered to the enrollee on May 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
You asked the Plan to pre-approve the POV. You say that you cannot walk far distances without losing your balance. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. A power wheelchair is needed when you are not able to use a normal (by hand) wheelchair in the home. It may also be needed when you are not able to walk with a cane or walker in the home. A Power wheelchair used for outside the home is not covered. You do not meet the guideline based on the records reviewed. Your records do not show you are not able to use a manual wheelchair home therapy check to see which walking aid will be best for you to safely walk in your home. Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora blood glucose monitor and diabetic testing supplies provided on May 14 -August 2, 2019.You asked the Plan to pay forthe blood glucose monitor and diabetic testing supplies. You say that  The Plan denied your request. The Plan says the delivery ticket submitted is not sufficient to verify the supply codes billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket did not include an order number and was not signed.Therefore, we decided that the Plan does not have to pay fora blood glucose monitor and diabetic testing supplies provided on May 14 -August 2, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on August 14, 2018.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says no authorization is on file for this service.
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 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 physician's services you provided on August 14, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on May 28, 2019 by the out of network provider.
You asked the Plan to pay for drug testing. You say that you were not aware that you needed an authorization for the drug test. The Plan denied your request. The Plan says the services were not emergent/urgent. The Plan's contract states you must receive care from a network provider with three exceptions: emergent or urgently needed services received from an out-of-network provider, care from out-of-network providers not available within the network, and kidney dialysis services from out-of-network providers when the member is temporarily outside the plan service area. The member must obtain authorization from the Plan prior to obtaining services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on May 28, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 12, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you never got charged before. You say that you should not be charged now. 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 $35 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a pulmonologist, which is considered a specialist. 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 the office visit provided on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from December 17, 2019 through discharge.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnight.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from December 17, 2019 through discharge
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says services provided in the LTACH are being provided already in the current acute care setting already approved.
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care with ventilator support and weaning trials, intravenous antibiotics, surveillance laboratory studies, periodic transfusions, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 long term acute care hospital (LTACH) services the enrollee.