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 the enrollee needs IRF services. The Plan denied your request. The Plan says the enrollee does not require full time access to a doctor or specialized equipment.
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 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. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve coronary computed tomography (CT) calcium scoring.
You asked the Plan to pre-approve CT calcium scoring. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CT calcium scoring. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has an intermediate 10-year risk of cardiovascular (CV) disease (10% using ACC CV risk calculator). He may benefit from statin therapy. In intermediate risk situations where there is a reluctance to use empiric therapy, additional risk enhancing factors (in this case coronary calcium scoring) can be obtained based on published guidelines to refine CV risk and determine whether lifelong statin therapy is clearly warranted. As this indication meets published society guidelines, coronary CT calcium scoring would be considered medically necessary in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT calcium scoring have been met. Therefore, we decided that the Plan has to pre-approve coronary computed tomography (CT) calcium scoring.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on January 29, 2021.
You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the transportation services provided on January 29, 2021.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.

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 that 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy (OT) services provided in the home on September 9, 2020 by an OT assistant (OTA).
You asked the Plan to pay for the OTA services. You say that these services should be covered. The Plan denied your request. The Plan says this was not billed with the correct code.
The Plan must follow Medicare rules. Medicare rules say that OTA services should be billed by the supervising therapist. The services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. In this case, these therapy services were billed by a nurse practitioner. Therapy services cannot be covered when provided incident to a nurse practitioner's services. Therefore, we decided that the Plan does not have to
pay for the occupational therapy (OT) services provided in the home on September 9, 2020 by an OT assistant (OTA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 28, 2020 and December 30, 2020.
You asked the Plan to pay for the laboratory services. You say that the Plan follows Medicare billing guidelines which does not require prior authorization for this test. You say that the claim should be processed toward payment. The Plan denied your request. The Plan says care must be received from a network provider.
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 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 laboratory services provided by an out-of-network provider on December 28, 2020 and December 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided by an out-of-network provider
from November 12, 2020, through December 21, 2020.

You asked the Plan to pay for the psychiatric services. You say that you are a current Medicare and Plan
provider. You say that the member contacted you due to increased depression and anxiety and was not aware
prior authorization was necessary. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan.

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
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 psychiatric services provided by an out-ofnetwork
provider from November 12, 2020, through December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
You asked the Plan to pre-approve the genicular radiofrequency ablation services. You say that the records provided support the need for the requested services. The Plan denied your request. The Plan says there is not enough medical evidence to support the use of genicular radiofrequency ablation services for the enrollee's condition.
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 genicular radiofrequency ablation services. Our reviewer says that genicular radiofrequency ablation services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has rheumatoid arthritis and osteoarthritis. She has had chronic right knee pain for 2 years which has been getting worse, She has had physical therapy and also wore a sleeve without improvement. She is doing a Home Exercise program. She had right genicular nerve blocks on November 24, 2020, with 95% pain relief for several days. Our physician reviewer found that genicular radiofrequency ablation is considered an experimental/investigational procedure. It is the subject of on-going clinical trials.
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 genicular radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on October 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received on October 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health physical therapy (PT) sessions (17 requested in total).
You asked the Plan to pre-approve the additional PT sessions. You say that you believe that the additional visits are necessary. The Plan denied your request. The Plan says with the approved six visits, further PT sessions in the home are not medically 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 the additional PT sessions. Our reviewer says that the requested number of PT sessions are not shown to be medically reasonable and necessary. Our physician reviewer found the enrollee has been receiving home health services after a hospital stay for sepsis and acute respiratory failure. He has received 19 home health PT visits as of the time of this request. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable and has been treated and approved for at least 23 HH physical therapy visits. He should be independent with 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 additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health physical therapy (PT) sessions (17 requested in total).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on January 22, 2021.
You asked the Plan to pay for the psychotherapy. You say that there are out-of-network benefits and the claim should be processed accordingly. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities are not eligible to enroll in Medicare. Medicare rules say that a provider or supplier must be enrolled in the Medicare program to receive payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy have not been met. This provider is a Master of Social Work. MSW's are not eligible to enroll in Medicare, therefore this provider is not payable. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve an initial 15 minutes of IV sedation (D9239), and an additional 15 minutes of IV sedation (D9243 x 3).
You asked the Plan to pre-approve the dental services. You say that the enrollee is in severe pain. You say that these teeth need to be surgically extracted at this time. You also say that the IV sedation is required due to the nature of the procedure and the enrollee's ability to effectively tolerate the treatment otherwise. The Plan denied your request. The Plan says that only 3 teeth have been approved for extraction. The Plan says that IV sedation is only covered when the enrollee needs a lot of work done on the same day. The Plan also says that the criteria for the IV sedation has not been met.
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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the deep sedation is medically necessary. Our physician reviewer found the enrollee has been approved to have 4 or more teeth extracted in 1 visit. Therefore, the reviewer found that the deep sedation is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve an initial 15 minutes of IV sedation (D9239), and an additional 15 minutes of IV sedation (D9243 x 3).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for the physical therapy (PT) and occupational therapy
(OT) services provided February 25, 2020, to February 26, 2020.

You asked the Plan to waive the copayment for the PT and OT services. You say that you feel that you should
not have to pay a bill 13 months later and the insurance should pay the bill or should not let them send a bill
this late. The Plan denied your request. The Plan says that per the Evidence of Coverage the enrollee is
responsible for $40 copayment for covered physical therapy services and $40 for covered occupational therapy
services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay $40 copay for Medicare covered occupational therapy visits
and $40 for physical therapy visits.

The Plan says you must pay $107.02 for the PT and OT services. Based on the Plan contract, however, you
cannot be asked to pay more than $80 ($40 + $40 = $80) for the PT and OT services. Therefore, we decided
that the Plan has to waive the copayment for $107.02 and the enrollee must pay $80 for the physical therapy
(PT) and occupational therapy (OT) services provided February 25, 2020, to February 26, 2020.

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: 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 admission to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says transfer to an LTACH is not necessary. All services that would be provided in the LTACH are being provided in the current acute care setting which is already approved. The enrollee is not required to discharge elsewhere to receive ongoing acute level care.
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 that the enrollee is currently receiving acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are currently receiving but that would be available at the LTACH facility. Criteria have not been met; 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 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the portable oxygen concentrator provided on December 16, 2020.

You asked the Plan to pay for the portable oxygen concentrator. You say that you attempted to obtain the device from a participating provider, but the service was declined. You say that prior authorization was not required for this service under the terms of the Plan. The Plan denied your request. The Plan says that durable medical equipment over $500 requires prior authorization.

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 says that durable medical equipment over $500 requires prior authorization. The Evidence of Coverage does not say prior authorization is required for every durable medical equipment purchase and the Plan did not provide any other rationale or evidence to support the denial. Therefore, we decided that the Plan has to pay for the portable oxygen concentrator provided on December 16, 2020.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from January 20, 2021, to January 21, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the total cost of your routine medications is approximately $3.17 per day. You also say that you do not understand why you are being billed $199.36 for 1 day worth of routine medication. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the self-administered drugs provided in an outpatient setting from January 20, 2021, to January 21, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.