Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carry over home assistance services of the 1st quarter
(January to March), to 2nd quarter (April to June).
You asked the Plan to pre-approve carry over home assistance services of the 1st quarter (January to March), to
2nd quarter (April to June). The Plan denied your request. The Plan says if the full number of visits is not used
in a quarter, the balance of visits is not carried over to be used in the next quarter. Quarterly periods are from
January to March; from April to June; from July to September; and from October to December.
The Plan contract says if the full number of visits is not used in a quarter, the balance of visits is not carried
over to be used in the next quarter. Quarterly periods are from January to March; from April to June; from July
to September; and from October to December.
We looked at the file and the Plan's rules. Based on this information, we decided that Medicare rules for
coverage of carry over home assistance services of the 1st quarter (January to March), to 2nd quarter (April to
June) have not been met. Therefore, we decided that the Plan does not have to pre-approve carry over home
assistance services of the 1st quarter (January to March), to 2nd quarter (April to June).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy with the requested out-of-network provider. The Plan denied your request. The Plan says your needs can be met in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the physical therapy services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for blood transfusion services provided on January 12, 2021, to January 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the blood transfusion services provided OON. You say that the records provided support that the services in dispute were medically necessary. The Plan denied your request. The Plan says enrollees must use network providers to get medical care and cervices. The services in dispute were not emergent, nor were they unavailable within the network.
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 blood transfusion services provided on January 12, 2021, to January 27, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home physical therapy (PT) visits.
You asked the Plan to pre-approve the PT visits. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not document why a skilled therapist is required to oversee your home exercise program.
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 the PT visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. She has previously been treated with home health physical therapy and instructed in a home exercise program. The requested home health services are 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 the PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Quetiapine Fumarate.
You asked the Plan to pre-approve Quetiapine Fumarate. You say that the enrollee is in long term care and stable on medication. You say that the drug being requested is medically necessary. You say that the enrollee is stable on current treatment and that removing him from dosing will send him into a psychotic episode. The Plan denied your request. The Plan says the drug in dispute is not covered under Part B and is intended for the patient's self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Quetiapine Fumarate. Benefits for Quetiapine Fumarate 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 pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance, half leg (E0673) provided February 9, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you believe there is a misunderstanding on the use of these place of service codes. You are requesting to have these claims re-evaluated. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance, half leg (E0673) provided February 9, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care admission.
You asked the Plan to pre-approve the SNF care admission. You say that your SNF admission was denied, and you would like to appeal. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met. 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 the SNF care admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for foundation Pain Index (FPI) testing (0117U) provided on February 23, 2021.
You asked the Plan to pay for the laboratory services. You say that please review the documentation provided to support the non-experimental medical necessity of this service. The Plan denied your request. The Plan says the clinical value and effectiveness of the Foundation Pain Index in the setting of chronic pain syndrome have not been demonstrated in the peer-reviewed literature. The state where the provider performs the service differs from the state where the enrollee resides. The provider is located in Kentucky, while the enrollee resides in Nevada. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices 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 the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical value and effectiveness of the Foundation Pain Index in the setting of chronic pain syndrome have not been demonstrated in the peer-reviewed literature. The request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for foundation Pain Index (FPI) testing (0117U) provided on February 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services. You asked the Plan to pay for the skilled nursing services. You say that the skilled nursing services should be paid for. The Plan denied your request. The Plan says the enrollee did not meet coverage criteria.
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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on February 22, 2021.
You asked the Plan to pay for the critical care services. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says no time is documented in the progress note.
The Plan must follow Medicare rules. Medicare rules say that for payment of critical care services, time must be documented in the record. Review of the progress note does not reveal that the time spent providing care is documented. Therefore, we decided that the Plan does not have to pay for the critical care services provided on February 22, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical services provided on March 2, 2020, billed with code 64999.
You asked the Plan to pay for the services as billed. You say that the services should be covered. The Plan denied your request. The Plan says that the operative report does not have specific documentation describing the services of this unlisted code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's decision is based on a review of the operative report. The case narrative includes a direct citation to the operative report. However, we reviewed the submitted file, and a copy of the operative report is not included. Without this documentation, we are unable to confirm that the Plan's denial is correct. As such, we find the denial is not substantiated. Therefore, we decided that the Plan has to pay for the surgical services provided on March 2, 2020, billed with code 64999.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve conduction study and electromyography to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the nerve conduction study and the electromyography. You say that you do not want to see another pain management doctor. You say your trust your provider who knows your treatment history. The Plan denied your request. The Plan says the provider is out-of-network
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the nerve conduction study and electromyography to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you live alone and feel that you would benefit from the SNF stay to regain strength before returning home as you have no support. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to skilled nursing facility does not meet the requirements for approval. 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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you have received oral medications. You had stable vital signs. Regarding rehabilitation services, you received physical therapy and occupational therapy in the SNF. By the dates in question, you were independent with functional mobility and with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (TFESIs).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that no more than two transforaminal injections may be
performed at a single setting.
We looked at the file and Medicare rules. The services are TFESI requested at three levels. 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 transforaminal epidural steroid injections (TFESIs).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you have ongoing treatment for stage 5 care. The Plan denied your request. The Plan says the benefit only allows 60
one-way transportation trips per calendar year and you have used 60 one-way transportation trips for this calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says that based on Medicare guidelines, your request for approval of admission to skilled nursing facility does not meet the requirements for approval. 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a supervision/stand by assist to contact guard assist level with functional mobility including gait to 80 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. As a practical matter, 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of skilled nursing facility services. 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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the acute hospital. The enrollee was at a supervision/stand by assist to contact guard assist level with functional mobility including gait to 150 feet with no AD. The enrollee was independent with wheelchair mobility and could negotiate 12 stairs with stand by assist. The enrollee required varying assist with activities of daily living. He worked with speech therapy on cognitive function. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.