Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to get proper treatment or be at risk for other infections. The Plan denied your request. The Plan says the enrollee has not completed their full course in the hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that in this case, the most recent records suggest ongoing acute care treatments. He is still dependent on mechanical breathing and is frequent bronchoscopy for mucous plug removal and atelectasis which is actively being treated at the current facility. There was no indication that intended services available at the proposed LTACH were not already available and covered at the current acute care facility, and no evidence that the required acute care services would be required for more than 25 days, considering his condition. Therefore, this request for LTACH transfer will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature. You say that the enrollee would benefit from a power seat elevation feature for positioning of transfers. The Plan denied your request. The Plan says a power seat elevation feature does not serve a medical purpose.
The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. 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 a power wheelchair power seat elevation feature.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee won't regain maximum function if he goes to a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's condition is not medically complex and does not require an interdisciplinary approach to rehab 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 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 the enrollee requires moderate assistance for ambulation and transfers, and moderate to maximum assistance with bed mobility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an eye exam provided on July 9,
2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that you are
required to use providers that are a part of your health 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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services for an eye exam provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 5, 2019.
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 would benefit from
placement in an LTACH facility. The Plan denied your request. The Plan says the enrollee is not clinically
stable and should remain in the current facility.
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 is a female who was admitted on 1/22/2020 with left sided chest pain and
shortness of breath. She was found to have possible pneumonia and was started on IV Zosyn, but the
consolidation worsened in spite of treatment. Hospital course also complicated by dysphagia, anemia and
weakness and deconditioning. The patient also had a cardiac catheterization in the hospital due to elevated
troponins and left ventricular dysfunction - five drug eluting stents were placed.
Based on the provided medical records the acute care hospital is able to provide all of the services the patient
requires. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care
such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home
with home health 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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on November 9, 2018.
You asked the Plan to waive the copayment for an ER visit. You say that the charges are fraudulent. 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 a $80 copayment for emergency care. The medical records show that you had an ER visit on November 9, 2018. Therefore, you are responsible to pay the $80 copayment. You have been asked to pay a $80 copayment for an ER visit. An ER visit falls within the emergency care 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 an ER visit provided on November 9, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visits provided from
August 5, 2019 to August 15, 2019.
You asked the Plan to waive the copayments for the emergency room visits. You say that you should not be
responsible for the copayments. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $120 copayment for each of the emergency room visits. The emergency room
visits fall within the "Emergency care" 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 copayments
for the emergency room visits provided from August 5, 2019 to August 15, 2019.
Your complaint about the poor service is not a valid appeal for medical coverage. This part of your complaint
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acute inpatient hospital services for the enrollee.
You asked the Plan to pre-approve acute inpatient care. The Plan denied your request. The Plan says the
enrollee was medically stable after January 27, 2020.
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.
The file shows that inpatient hospital care from January 26, 2020 to January 30, 2020 was requested for the
enrollee. The plan agreed to approve inpatient care from January 26-27, 2020. 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 continued acute inpatient care. Our physician reviewer found that
the enrollee presented with increased warmth/cellulitis of the right great toe. The evaluation revealed a toe
ulcer with gangrenous changes right 1st toe. Lab studies revealed no elevated WBC. She was treated with IV
fluids and IV antibiotics. There was no evidence of osteomyelitis. She was hemodynamically stable. The
review indicates that as of January 27, 2020, the enrollee was hemodynamically stable and no longer required
inpatient level of care services. She did not receive any inpatient diagnostic studies or therapeutic interventions
as of January 27, 2020. The record did not show that continued inpatient care beyond Jan 27, 2020 was
reasonable and 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 acute inpatient care have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued acute inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve out-of-network surgery (27447).
You asked the Plan to pre-approve out-of-network surgery (27447). You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says that the requested services are neither
emergent nor urgent to seek out-of-network care as the requested services could be provided in-network.
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. Specifically, the Plan did not provide enough documentation to support their
reason for denial based on Medicare guidelines. A complete case file, per Medicare guidelines includes all
documentation used to support the Plan's denial. The case file does not include any supporting documentation
to demonstrate that the Plan's decision meets Medicare guidelines.
A request for information was sent to the Plan on January 23, 2019 for this information with no response from
the Plan. The case file clearly demonstrates that the enrollee and the provider believe the requested surgery
includes a technique unavailable in New Mexico where the enrollee's service area is. We requested the Plan to
clarify what this technique was and if the Plan had providers available that could also perform the requested
surgery using the same technique. We also requested a list of in-network providers from the Plan to ensure the
requested surgery using this technique could be provided in-network. The Plan has not responded to our
requests. Therefore, we decided that the Plan has to pre-approve out-of-network surgery (27447).
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 LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the longer the enrollee remains on a ventilator he will decline and develop. The Plan denied your request. The Plan says the enrollee is too unstable for transfer at this time.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that in the case of this enrollee, the most recent records suggest a deteriorating clinical status which was too unstable for discharge. He is still dependent on mechanical breathing and is having fevers, hypotension, and signs of sepsis which is actively being treated at the current facility. Transfer would not be appropriate at this time. There was no indication that intended services available at the proposed LTACH were not already available and covered at the current acute care facility. Therefore, this request for LTACH transfer will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on September 19, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the denied claim as the notes will support the need for service. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. There is not a referring provider. The Plan did not authorize any services for this doctor. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on September 19, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit/Epogen for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says it is unknown if there has been a trial and failure of Retacrit.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found there is no evidence of a trial and failure of Retacrit. The documentation does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit/Epogen for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on September 24, 2019.
You asked the Plan to waive the coinsurance for genetic testing. 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 molecular diagnostic/genetic testing. You received genetic testing on September 24, 2019. The allowed amount is $3,873 and 20% of that is $647. You have been asked to pay the total coinsurance amount of $647 for genetic testing. Genetic testing falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing provided on September 24, 2019.
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 needs this LTACH care. The Plan denied your request. The Plan says the enrollee's needs are met in the current 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 is a female with pulmonary fibrosis and interstitial lung disease on the waiting list for a lung transplant. She was in an acute hospital 12/30/2019 - 1/10/2020 with pneumonia, then she was transferred to a skilled nursing facility where she was 1/10/2020 - 1/26/2020 - now discharged to custodial level of care. She has been receiving physical therapy and walks with a wheeled walker. Transfer to a long term acute care hospital (LTACH) is requested. Based on the provided medical records the long term care facility is able to provide all of the services the patient presently requires. Care from an LTACH is not medically reasonable and 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 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.