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

We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure (CPAP) equipment (E0601), provided on January 14, 2021, through March 14, 2021
You asked the Plan to waive the coinsurance for CPAP equipment. You say that you should not be responsible for a cost share. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a 20% coinsurance for CPAP equipment. CPAP equipment falls within the durable medical equipment and related 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 coinsurance for continuous positive airway pressure (CPAP) equipment (E0601), provided on January 14, 2021, through March 14, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that it would not be safe for the enrollee to
return home at this time. You say that the complexity of the enrollee's condition would make for her to be
better served in an LTACH setting. The Plan denied your request. The Plan says the level of care provided in
an LTACH is more than the enrollee's medical conditions need.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted to the current acute care hospital with hip joint infection
related to left replaced hip joint which was removed. She received IV antibiotics and dialysis. The course was
complicated by gastric ulcer requiring surgery and has had bleeding complications related to such requiring
transfusions. She has since been weaned from mechanical ventilation but still has encephalopathy. Recent CXR
shows worsening infiltrates. The enrollee appears to be unstable still and requires short-term acute care to
complete treatment which can safely be performed at the current facility.
The enrollee does not require services at the LTACH that are not already available and/or being administered at
the current facility. There are no services at the LTACH that the enrollee requires that are not already available
and covered at the current facility. There is no advantage to transfer and the enrollee is not yet stable enough.
Transfer may be considered when the enrollee is more stable and treatment has completed.
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
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed with bronchial thermoplasty, 1 lobe (CPT code(s): 31660 and 31661), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bronchial thermoplasty in the setting of asthma have not been demonstrated in the peer-reviewed literature.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has asthma. The available literature does not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.
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 bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed with
bronchial thermoplasty, 1 lobe (CPT code(s): 31660 and 31661), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services, initial 15 minutes (99152) and moderate sedation, each additional 15 minutes (99513) provided September 24, 2020.
You asked the Plan to pay for the sedation services. You say that you are requesting this claim be reconsidered as it was denied. Please review the claim with documents and reprocess for payment. The Plan denied your request. The Plan says the records do not support the service billed.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, initial 15 minutes of intra-service time, patient age
5 years or older and 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intra-service time (list separately in addition to code for primary 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 sedation services. Our reviewer says that the documentation does not support the criteria for the services. Our physician reviewer found the operative report does not include documentation of a qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports requiring the presence of an independent trained observer to assist in the monitoring of the enrollee during procedure per CPT 99152 and CPT 99153 description, therefore, this service cannot be confirmed as 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 the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services, initial 15 minutes (99152) and moderate sedation, each additional 15 minutes (99513) provided September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee no longer requires ICU level
of care, and his needs would best be met at an LTACH that specializes in his type of case. You say that the
LTACH interdisciplinary/integrated care model offers the potential for the best outcome for the enrollee. The
Plan denied your request. The Plan says LTACH care is not medically necessary. The Plan says that all the care
needed can be safely managed in the current care setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be unstable still and requires short-term acute care to
complete treatment which can safely be performed at the current facility. The enrollee does not require services
at the LTACH that are not already available and/or being administered at the current facility.
There are no services at the LTACH that the enrollee requires that are not already available and covered at the
current facility. There is no advantage to transfer and the enrollee is not yet stable enough. Transfer may be
considered when the enrollee is more stable and treatment has completed.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the specialist office visit provided on February 12, 2021.
You asked the Plan to adjust the copayment for the specialist office visit. You say that you did not see the specialist so the specialist copayment should not apply. The Plan denied your request. The Plan says you were charged this copayment 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 Physician Services, specialist. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the Physician Services, specialist benefit category. You were seen in a specialist office by a provider under the supervision of the pulmonary 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 adjust the copayment for
the specialist office visit provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitoring system.
You asked the Plan to pay for therapeutic continuous glucose monitoring system (K0553, K0554). You say that the CGM was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The physician notes from the current office visit do not show the physician discussed a CGM with the enrollee therefore medical necessity is not adequately supported. Based on this information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitors have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitoring system.
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 clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. The enrollee 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 enrollee 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 pay for durable medical equipment provided on August 5, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 durable medical equipment provided on August 5, 2020 by an out-of-network (OON) provider
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and servic
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says there is not a medical need for care in an IRF because the enrollee does not need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for Parkinson's disease and frequent falls. The enrollee's medical conditions are stable. There are
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The
enrollee 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 enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 7, 2020.
You asked the Plan to pay for lab tests. You say that you request that the Plan does not penalize you for being out-of-network. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 7, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on August 27, 2020.
You asked the Plan to pay for progressive lenses. You say that the Plan told you the claim was missing codes needed to cover your cataract glasses. The Plan denied your request. The Plan says any upgrades including progressive lenses are not covered under your vision medical benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers standard frames and lenses after cataract surgery. Any upgrades are not covered by the plan, including progressive lenses. We looked at the file and the Plan's rules. The Plan confirms any upgrade to the progressive lenses are not covered under your vision benefit. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on December 29, 2020.
You asked the Plan to pay for progressive lenses. You say that you have a $120 yearly eye wear allowance for frames and lenses and the claim you submitted is for glasses after surgery. The Plan denied your request. The Plan says progressive lenses are not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan does not cover these services.
We looked at the file and the Plan's rules. The progressive lenses and anti-reflective coating which you
purchased are not covered benefits of Medicare or the Plan. Based on this information, we decided that the
Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not
have to pay for progressive lenses (V2781) provided on December 29, 2020