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

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on September 14, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for DME and related supplies. You received DME and related supplies on September 14, 2020. The total allowed amount is $1,234.10 and 20% of that is $246.82. You have been asked to pay the total coinsurance amount of $246.82 or DME and related supplies. DME and related supplies fall within the DME 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 DME and related supplies provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve negative pressure wound therapy electrical pump,
stationary or portable (CPT Code E2402).

You asked the Plan to pre-approve the DME. You say that the DME is 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 DME have not been met. The enrollee does not meet criteria of
medical necessity as the enrollee has used the device on the same wound for over 4 months without resolution.
Therefore, we decided that the Plan does not have to pre-approve negative pressure wound therapy electrical
pump, stationary or portable (CPT Code E2402).
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-approve IRF care. The Plan denied your request. The Plan says your rehab needs are not complex enough to require coordinated care between therapy disciplines.
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 physician reviewer found that you were admitted to the acute hospital for a fall, and were treated for thoracic discitis. Your medical conditions are stable. You have no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: 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 these services are medically necessary.
The Plan denied your request. The Plan says that there is no documentation that the enrollee will benefit from
and improve with LTACH management.
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. The patient
appears to be improving and requires only short-term acute care services to help complete the required
treatment in a hospital setting. The patient does not require services at the LTACH that are not already
available at the current facility. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing services.
You asked the Plan to pre-approve the continued skilled nursing services. You say that you do not feel that the
enrollee has reached her base line, and you think the enrollee has a little further to go. The Plan denied your
request. The Plan says the enrollee no longer requires skilled services and the continuation of SNF is not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 continued skilled nursing services.
Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer
found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires
the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for
coverage of the continued skilled nursing services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve the requested services. You say that recent data supports the clinical benefit of remote hemodynamic monitoring. The Plan denied your request. The Plan says the service is unproven as treatment for any indication.
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 requested services. Our physician reviewer found that the enrollee has a history of diabetes, hyperlipidemia, hypertension, hypothyroidism, obesity, peripheral arterial disease, coronary disease and Class III congestive heart failure requiring hospital admission. In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMEMs device is uncertain at this time according to leading authorities, and not recommended in current guidelines for the treatment of heart failure. Therefore the requested device is considered experimental. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
You asked the Plan to pre-approve the system. You say that this device will allow the provider to better monitor and manage symptoms that lead to repeated heart failure hospitalizations. The Plan denied your request. The Plan says currently, this device is under study to see if monitoring is reasonable and necessary for the management of heart failure.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a
participating provider on July 28, 2020.
You asked the Plan to waive the copayment for physician services. You say that you went for you annual. You
say that you thought this would be a $0 copayment. The Plan denied your request. The Plan says the correct
copayment has been applied.
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
copayment for physician/practitioner services/specialist.
You have been asked to pay $16.99 which is less than your copayment amount of $20 for physician services.
When additional services are provided during an office visit, additional copayments can be applied; therefore,
the correct copayment has been applied. Physician services fall within the physician/practitioner
services/specialist benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physician services
provided by a participating provider on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that the item would be beneficial to your health. The Plan denied your request. The Plan says Medicare does not cover this item because it is considered hygiene equipment and is not medical in nature.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Specifically, the item requested is considered hygiene equipment and is not considered medically necessary. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on
August 14, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for this service was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on August 14, 2019.
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-approve IRF care. You say that the stay is 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 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 enrollee's
medical status does not currently require intensive physician or nursing supervision in an IRF. While the
enrollee may benefit and participate in multiple therapies the enrollee's functional level does not require this
therapy on an 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.
You asked the Plan to pre-approve inpatient services. You say that the enrollee's evaluation and treatment plan
is not complete. The Plan denied your request. The Plan says an observation stay would meet the enrollee's
medical needs.
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 pre-approve inpatient services. Our physician
reviewer found that the enrollee presented to the emergency department with abdominal pain and
hematochezia for a few days. She has a history of chronic anemia. She was noted to not be in any acute
distress, and her examination was non-toxic. Her vitals were stable, she was treated with conservative care, and
did not have any more bleeding, and was admitted to the hospital. The records do not show that the enrollee
requires inpatient hospital care, as she was stable and was tolerating conservative care. The records also
showed that it was not expected that she would require hospital care that would cross two midnights. Therefore,
this request for inpatient services are considered 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 inpatient services have not been met. Therefore, we decided that the Plan does
not have to pre-approve acute inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Escape Lift Chair for the enrollee.
You asked the Plan to pre-approve the chair. You say that this is needed due to the enrollee's back pain. The Plan denied your request. The Plan says the seat lift mechanism can be covered, but the chair itself cannot.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an Escape Lift Chair 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-approve IRF care. You say that the stay is 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for spinal decompression and fusion to treat spinal stenosis. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery (22869, 22870).
You asked the Plan to pre-approve the Vertiflex surgery. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertiflex device surgery is not medically necessary and is experimental/investigational.
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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Superion Vertiflex indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex surgery (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 25, 2020.
You asked the Plan to pay for . You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 80307 and G0482 are not supported.
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 80307 is presumptive drug testing, any number of drug classes. The description of code G0482 is definitive drug testing, 15-21 drug classes. We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, there are no submitted lab results for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you originally sent this in a timely manner. The Plan denied your request. The Plan says the rendering physician is out-of-network. The Plan says that the referring provider is also out-of-network. The Plan says that the member's primary care physician did not refer these 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 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 podiatry services provided on February 4, 2020 by an out of network (OON) provider.