Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on February 22, 2021.
You asked the Plan to waive the copayment for eye exam. You say that you were seen for a no charge preventive visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $10 copayment for eye exam. You have been asked to pay $10 copayment for eye exam. Eye exam falls within the Vision 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 eye examination provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special power wheelchair (Group 3 Power Wheelchair with Single Power Option) (CPT code (s): K0858, E2623, E0955, E1028, E2363, E2300, E1012, E2377, E2621, E2311, E2313), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says Medicare guidance says that a special power wheelchair (Group 3 Power Wheelchair with Single Power Option) is medically necessary for individuals that require either power tilt or power recline. Neither of these power options (power tilt or power recline) is requested for this wheelchair. Upgraded electronics (expandable controller, harness and electronics) cannot be covered per Medicare rules. There is not a medical need to control more than two power options though the joystick. The notes do not show that you have a medical need for the power leg lifts.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 DME. Our physician reviewer found there is no documentation that requirements have been met as defined in the LCD/NCD for the specific requested group 3 power wheelchair with single power option and upgraded electronics as power tilt and recline have not been requested for the wheelchair. Although the records do not document criteria for coverage of a group 3 power wheelchair with single power option, the enrollee does appear to meet criteria for a group 3 power wheelchair with no power option. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve special power wheelchair (Group 3 Power Wheelchair with Single Power Option) (CPT code (s): K0858, E2623, E0955, E1028, E2363, E2300, E1012, E2377, E2621, E2311, E2313), for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion or replacement of the Optimizer Smart permanent cardiac contractility modulation system (CPT code 0408T).
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are considered experimental and 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of clinical congestive heart failure (CHF) on the in-office clinical exam, no recent hospitalizations for decompensated CHF and you are only on low dose spironolactone and no other diuretics at present. You have a biventricular implantable cardioverter-defibrillator (ICD) but your QRS is still very wide at 0.21 sec and there is no report of any adjustments to the biventricular ICD/pacing device to increase left ventricle (LV) pacing to optimize synchronous ventricular contractions. Although Food and Drug Administration (FDA) approved, there is only limited data to suggest that Optimizer therapy in this clinical situation will improve exercise capacity and quality of life scores when medical, anti-ischemic and the previously done cardiac resynchronization therapy (CRT) device therapy has not been well optimized. Based
on the current reported clinical situation and treatments, you would not meet the medical necessity and reasonableness criteria of the applicable Centers for Medicare and Medicaid Services (CMS) Section1862(a)1(A) rule for use of the Optimizer contractility modulation device therapy 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion or replacement of the Optimizer Smart permanent cardiac contractility modulation system (CPT code 0408T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection of diagnostic or therapeutic
substance provided on March 18, 2021.
You asked the Plan to waive the copayment for these services. You say that you should not be charged. The
Plan denied your request. The Plan says that you were charged in accordance to your benefit.
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 $200
copayment for services provided at an ambulatory surgical center.
You have been asked to pay a $200 copayment for these services. You received an injection at an ambulatory
surgical center. These services fall within the services provided at an ambulatory surgical center 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 the injection of diagnostic or therapeutic
substance provided on March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee currently lives in a group home and there are only two individuals there to care for a group of eight. You say that it is not safe for the enrollee to return to the group home safely. You say that the enrollee has very large kidney stones, has had 10 mini strokes, and is currently bed ridden. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services or skilled therapy services. The medical records provided do not show that the enrollee requires services on an inpatient basis, only in a SNF setting. The services needed could be provided in a long-term care facility or on a part-time basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for a primary care office visit provided on March 2, 2021.
You asked the Plan to waive the deductible for office visit. You say that you have no copayments or any payment with this Plan. The Plan denied your request. The Plan says that the deductible amount you are being charged is correct.
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 does not establish a deductible for any items or services received in 2021. Furthermore, the Plan contract says that enrollees pay $0 copayment for provider and professional services by either a primary care or specialist provider. You can find this information in Chapter 4 on page 78 of the Plan's 2021 Evidence of Coverage. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $126.50 deductible amount for primary care office visit. The Plan contract does not clearly say that any deductible amount applies to a primary care office visit. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for a primary care office visit provided on March 2, 2021.
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: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says that your records do not show the required conditions for approval of an inpatient admission to the hospital.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that your necessary hospital care (including earlier emergency department (ED) and/or observation care) will span two midnights. 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 hospital care have been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient hospital care.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the adult size Pull-On LG (T4257), provided on November 17, 2020.
You asked the Plan to pay for the adult size Pull-On LG. You say that the item should be covered. The Plan denied your request. The Plan says for over-the-counter items to be covered, you must order the supplies from the Plan's vender with the Plan's quarterly allowance.
The Plan must follow Medicare rules. Medicare rules say that MA plans may choose to offer some benefits to enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits they are required to offer if the item or service also meets the criteria. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adult size Pull-On LG have not been met. Specifically, you did not order this item through the Plan's vendor. This means the item is not covered. Therefore, we decided that the Plan does not have to pay for the adult size Pull-On LG (T4257), provided on November 17, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is in need of strength and endurance training to improve his mobility and ability to tend to activities of daily living (ADLs). Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has failed greater than six (6) months of conservative approaches include rest and/or restricted activity, pain mediation, physical therapy, and epidural steroid injections. The Plan denied your request. The Plan says the services are considered experimental and 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-5 is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 5, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. We looked at the file and Medicare rules. The provider is not a Medicare-certified provider. 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 pay for the laboratory services rendered on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82542, 84228, G0481) provided on
December 9, 2020, by an OON provider.
You asked the Plan to pay for OON laboratory services. You say that you were not aware authorization was
required. The Plan denied your request. The Plan says OON services require 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 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 laboratory services (82542, 84228, G0481)
provided on December 9, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 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 hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care