Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the services (CPT 99244) provided to you by a contracted provider on August 27, 2019.You asked the Plan to hold you harmless forthe services. You say that you only had an office visit on this date.The Plan denied your request. The Plan says that this is not a covered service.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. Prominence follows these rules.You were provided the services by contracted provider. You have no control over how the provider codes and bills the services provided to you. The file does not show that Prominence provided notice that the services would not be covered. Under Medicare rules, this means the services are considered approved by Prominence.Therefore, we decided that the Plan has to hold you harmless forthe services (CPT 99244) provided to you by a contracted provider on August 27, 2019
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 5, 2020 with meningiomas. The physical therapy note dated February 12, 2020 states she needs contact guard assist to stand up and minimal assist to walk 50 feet with a rolling walker. She needs set-up for bathing and grooming and minimal assist for dressing per the occupational therapy note dated February 12, 2020. She does not require the intensity of services at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: 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-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was readmitted to the hospital with subsequent intubation and tracheostomyplacement. He is being actively weaned from the ventilator and does not require any services at the LTACH that are not available at the current setting. He does not require any services that are not available at the health care setting being offered by the health plan. The LTACH services are not reasonable or 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean axial rotation unit and flex foot system for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that the enrollee's physician or therapist does not corroborate any change in weight or medical condition of member that requires a replacement of the member's current foot.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 these services. Our reviewer says that these services are not medically reasonable and necessary for the enrollee in this case. Prior to the enrollee's amputation he was independent with mobility and ADLs. He has been utilizing a preparatoryprosthesis and has been approved for a definitive prosthesis with the exception of the axial rotation (L5986) unit and flex foot system (L5980). The vendor's records indicate the enrollee is a K3 ambulator, but there are no medical records to support this. Based on available records, the patient does not meet criteria for coverage of an axial rotation (L5986) unit and flex foot system (L5980). The medical records do not support the enrollee as a functional level of 2 or 3. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these items.We looked at this physician's review, the file, and Medicare rules. 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-approvean axial rotation unit and flex foot system for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on September 6, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services do not meet the diagnosis requirement.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination tilt and recline power seating system for a power wheelchair.You asked the Plan to pre-approve these services. You say that you need the wheelchair to get around.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a tilt and recline power seating system is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have inflammation and deterioration of cartilage of the left knee. There is no documentation of a significant impairment in your upper limb strength or coordination. The requested power seat system would be a convenience item. The records do not show that you are not able to transfer yourself from sitting to standing. The item is therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a combination tilt and recline power seating system for a power wheelchair
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost share forthe emergency room visit provided on September 18, 2019.You asked the Plan to reduce the cost share forthe emergency room visit. You say that you passed out and were taken to an out-of-network hospital. You say this bill should have been much less because this was an emergency and you were taken to the closest hospital. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.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 did not submit medical records to support that the hospital services were provided on an outpatient basis and not on an emergency basis. Therefore, the plan has not shown that the coinsurance amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to reduce the cost share forthe emergency room visit provided on September 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 25, 2019 to April 11, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this treatment because the authorization code is missing.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required Treatment Authorization Code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 25, 2019 to April 11, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Holter monitoring up to 48 hours.You asked the Plan to pre-approvethe Holter monitoring. You say that this monitoring is needed due to risk factors and prior history.The Plan denied your request. The Plan says that there are no current signs or symptoms of cardiovascular disease so this testing is not warranted.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Holter monitoring. Our reviewer says that the requested services are considered medically reasonable and necessary in this case.Our physician reviewer found the patient has a history of stroke, hypertension and diabetes. He has not been previously evaluated for paroxysmal atrial fibrillation (AF) as a cause of his prior stroke. He has no other known cause of cerebrovascular disease as the etiology of his prior stroke. Given his severe hypertension (which is not currently well controlled) and diabetes, he is a higher risk for atrial rhythm disturbances. The use of Holter monitoring to assess for paroxysmal AF in patients with prior ischemic stroke is a reasonable, medically indicated use of the technology with published literature to support its use. The use of Holter monitoring is therefore both medical necessary and indicated for the diagnosis and treatment of this condition. In addition, a finding of paroxysmal AF would substantially change the medical management of this patient.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 Holter monitoring have been met.Therefore, we decided that the Plan has to pre-approveHolter monitoring up to 48 hours.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections.
You asked the Plan to pre-approve the Synvisc injections. You say that the provider's office does not carry Monovisc so Synvisc should be allowed since this is what the provider uses. The Plan denied your request. The Plan says coverage for non-preferred viscosupplements is only allowed if there is a medical contraindication to the preferred agents.
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 Synvisc injections. Our reviewer says that the requested drug is not medically reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has a diagnosis of pain in the right knee due to osteoarthritis. There has been no trial of the plan's preferred drugs. The documentation does not support that Orthovisc and Monovisc 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 Synvisc injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for EPI testing provided to the enrollee on October 4, 2019.
You asked the Plan to pay for the testing. You say that this is medically necessary, and there was no payment on the claim. The Plan denied your request. The Plan says this is not listed by Medicare guidelines as being medically necessary.
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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the review has determined that the enrollee does not meet the criteria for this testing.
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 testing have not been met. Therefore, we decided that the Plan does not have to pay for EPI testing provided to the enrollee on October 4, 2019.
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 would benefit from IRF care. The Plan denied your request. The Plan says IRF criteria are not met.
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 patient'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 patient's medical status required the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient's fatigue level does not indicate that he requires this therapy 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a disposable insulin delivery system known as Omnipod.
You asked the Plan to pre-approve Omnipod. You say that the enrollee has been stable with her infusion pump for several years and you do not want to risk switching her to a different type of pump. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because Omnipods are not covered by Medicare's medical benefits. The Plan also says that they will approve coverage for Omnipods under the enrollee's pharmacy benefits administered by the facility.
The Plan must follow Medicare rules. Medicare rules say that Omnipods are not covered by Medicare's medical benefits because they do not meet the Medicare definition of durable medical equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Omnipod have not been met. Therefore, we decided that the Plan does not have to pre-approve a disposable insulin delivery system known as Omnipod.
Benefits for Omnipod 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a trauma response team associated with hospital critical care service (G0390) provided on August 9, 2019 through August 10, 2019.You asked the Plan to pay for the trauma response team. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says G0390 denied due to OCE edit 76 for a trauma response critical care code present without CPT code 99291 billed on the same date of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code G0390 is not supported in the record. Specifically, in order to receive additional payment for G0390, it must be reported with CPT codes 99291 or 99292. G0390 has been reported without a required critical care CPT code. Based on this information, we decided that Medicare rules for coverage of the trauma response team have not been met. Therefore, we decided that the Plan does not have to pay for a trauma response team associated with hospital critical care service (G0390) provided on August 9, 2019 through August 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services you received on July 25, 2019.
You asked the Plan to pay for the services. You say that you should be reimbursed the full amount. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $10 copayment for each specialist's office visit for outpatient mental health care. Review of the file shows that you had a specialist visit on July 25, 2019. You have been asked to pay a $10 copayment for the services. The services falls within the each specialist's office visit for outpatient mental health 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. Please note that the plan has reimbursed you for the Medicare allowed amount of $79.64. If you wish to be reimbursed the balance, you must request this from the provider, as you paid up front for the services. Therefore, we decided that the Plan does not have to pay for the mental health services you received on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says you do not have an indicated diagnosis for this request.
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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case.
Our physician reviewer found in the case of this enrollee, the listed diagnosis, radiation proctitis, is not an approved and proven indication for HBO therapy. The records provided did not reveal any other approved indication to help support this request. Therefore, this request for HBO therapy will be 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 9, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 subsequent nursing facility care provided on September 9, 2019.