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

We decided that the Plan does not have to pre-approve an extra battery for a portable oxygen concentrator.You asked thePlan to pre-approvean extra battery. You say that the enrollee needs to have the ability to be away from her home concentrator for more than 4 hours at a time.The Plan denied your request. The Plan says the item requested is considered a convenience item.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that the enrollee has a portable oxygen concentrator that includes a battery, battery charger, and power adapter.  The included battery serves the same purpose as the requested extra battery. Therefore, we decided that the Plan does not have to pre-approvean extra battery for a portable oxygen concentrator
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 you are not ready to be discharged. You say that you are still not able to walk on your own and have no one at home that can help you.The Plan denied your request. The Plan says the clinical information does not show that the enrollee requires the active and ongoing therapeutic intervention of multiple 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical conditions appear stable and there are no complex wound care needs. There are no unaddressed medical issues and the enrollee does not require medical oversight of her condition at an acute hospital level of care. The enrollee requires physical therapy for progression of her mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. However, the enrollee is ambulating greater than household distances and has been progressed to stair climbing. The enrollee is performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. The enrollee's care can be appropriately provided through home-based and outpatient services with intermittent scheduled services for lower body activities of daily living if needed. If stair climbing is an issue, this would most appropriately occur on the actual stairs in the home setting. Rearrangement of the living space or use of adaptive equipment would be examples of ways in which a stair climbing deficit could be addressed.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 pay for an inpatient hospital stay provided from May 13, 2019 to May 15, 2019.
You asked the Plan to pay for an inpatient hospital stay. You say that your Plan did not notify the hospital of the post-stabilization denial and that the enrollee was not stable for transfer to another facility and required a 3-day inpatient stay. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 11:06 am on May 13, 2019. Subsequent care was post stabilization care and not approved in compliance with the health plan's authorization procedures. The Plan paid for all emergent care up to the point of stability.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 an inpatient hospital stay. Our reviewer says that the service was not medically necessary. Our physician reviewer found that the enrollee presented with a chief complaint of right-sided weakness after a brief syncopal episode without loss of consciousness. In the emergency room (ED), the enrollee was alert however had difficulty communicating verbally. The enrollee's physical examination revealed profound right-sided weakness predominantly in the face, and right arm/right leg. A computed tomography scan (a CT scan) of the head showed a hemorrhage. In the ED, the enrollee was treated with intravenous (IV) fluids. The medical record stated that by 11:06 am on May 13, 2019 the enrollee was evaluated by Neurosurgery and was declared stable and did not require any neurosurgical intervention. The enrollee was stable for transfer to the nearest facility. The enrollee was alert and oriented, had improvement in extremity strength and was stable. All lab test results and diagnostic imaging confirmed the enrollee's emergency neurologic condition to be stabilized.
The review has determined that the post-stabilization care services after 11:06 am on May 13, 2019 to May 15, 2019 were not medically necessary and reasonable. The review determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay provided from May 13, 2019 to May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology exam provided on
October 22, 2019.
You asked the Plan to waive the copayment for the ophthalmology exam. You say that you found out the visit
was covered under your medical benefits. You say that since you were informed you would not have a
copayment for a routine visit, you should not be assessed the copayment. 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 $35
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye.
You have been asked to pay a $35 copayment for the ophthalmology exam. The ophthalmology exam falls
within the "Vision care" benefit category. The record shows a diagnosis of age-related cataracts which makes
the exam medical in nature.
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 ophthalmology exam provided on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a pneumatic compression device (PCD) coded as E0652 to be provided from an out of network (OON) supplier.
You asked the Plan to pre-approve the OON PCD. You say that the enrollee should be covered for this device. The Plan denied your request. The Plan says that there is no evidence that the criteria for this type of PCD are met nor that it is necessary from an OON supplier.
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. In this case, the Plan only provided documentation from the original authorization request, limited to the order form from the supplier. The file notes that the treating physician faxed in a request for expedited appeal on February 12, 2020, but this documentation is not found in the file, nor are any medical records. It is not clear whether the plan made a good faith attempt to obtain any medical records. We requested the Plan to forward both a copy of the appeal requested faxed on February 12 and relevant medical records. To date, no response was received. Without this information, we are not able to ascertain whether the criteria for coverage are met. Therefore, we decided that the Plan has to pre-approve a pneumatic compression device (PCD) coded as E0652 to be provided from an out of network (OON) supplier.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 5, 2019 to
April 16, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not have skilled nursing or skilled rehabilitation needs nor did he receive skilled therapy only available at a
skilled nursing facility.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from April 5, 2019 to April 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant 60mg DR capsules.
You asked the Plan to pre-approve the Dexilant capsules. You say that this is needed. The Plan denied your request. The Plan says this is an oral drug which is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexilant 60mg DR capsules.
Benefits for the Dexilant capsules 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says the current provider needs to be worked with to find the best portable system for your
needs.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
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 system is not medically reasonable or necessary. Our physician reviewer found you are requesting a
more manageable portable oxygen system to make it easier to travel. You already have a portable oxygen
system at home. The records do not specify the type. Medicare covers portable oxygen systems for mobility
within the home. However it does not cover duplicate portable oxygen systems, and it does not cover portable
oxygen concentrators for the purposes of travel; this is considered a convenience. A second portable oxygen
system is therefore 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 system have not been met. Therefore, we decided that the Plan does not
have to pre-approve a portable oxygen system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan of the abdomen.You asked the Plan to pre-approvea CT scan of the abdomen. You say that the requested CT scan of the abdomen is medically necessary.The Plan denied your request. The Plan says the requested CT scan of the abdomen is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve a CT scan of the abdomen. Our reviewer says that the requested CT scan of the abdomen is not medically necessary. Our physician reviewer found the enrollee with chronic upper abdominal pain was reported with afailed trial of antacids, Bentyl, Mylanta, GaseX, and Gaviscon. The enrollee saw the gastroenterologist who diagnosed constipation and did not recommend any testing or new medication options. The treating physician wished to acquire CT imaging to rule outbile duct stones or mass in the pancreas. No abdominal examination findings were provided, nor was there report of any x-rays or ultrasounds of the abdomen found in the provided records. As there was insufficient objective clinical information from examination or unclear less invasive imaging and test results, there is insufficient justification made for this request. No signs or symptoms suggestive of a red flag diagnosis were apparent to justify early CT scanning. Therefore, the requested CT scan of the abdomen 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 a CT scan of the abdomen have not been met.Therefore, we decided that the Plan does not have to pre-approvea CT scan of the abdomen.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of spinal instrumentation and spinal fusion of C6-C7.
You asked the Plan to pre-approve the spinal fusion procedure with hardware removal. You say that the enrollee requires this intervention to treat her condition. The Plan denied your request. The Plan says this is not needed without symptomatic myelopathy or radiculopathy.
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 spinal fusion procedure with hardware removal. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent fusion of the cervical spine in 2011. An anterior plate and screw fixation spans C4 - C7. Flexion and extension views of the cervical spine on 2/6/20 revealed multilevel degenerative changes, with no dynamic instability. CT imaging of the cervical spine on 1/31/20 did not exclude a diagnosis of pseudoarthrosis at the C6-7 level, however, no acute abnormalities were noted. The neurological exam by the neurological surgeon on 2/5/20 showed normal coordination and intact sensation. Deep tendon reflexes were normal. The exam documents 5/5 strength in the upper and lower extremities. Tone was normal. There was no significant antalgic or myelopathic component. The documentation is insufficient to demonstrate that cervical spine surgery with removal of prior instrumentation is medically reasonable and necessary for the enrollee in this case. The enrollee reported pain, but it is not quantified. There is insufficient discussion of conservative measures tried and failed. The enrollee's neurological exam is unremarkable. It is not clear from the documentation in the case file that surgical intervention is appropriate to treat her symptoms. 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 spinal fusion procedure with hardware removal have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of spinal instrumentation and spinal fusion of C6-C7.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remaining 9 home health physical therapy (PT) visits.
You asked the Plan to pre-approve the remaining 9 home health physical therapy (PT) visits. You say that the remaining 9 home health physical therapy visits are medically necessary. The Plan denied your request. The Plan says the remaining 9 home health physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 remaining 9 home health physical therapy (PT) visits. Our reviewer says that the remaining 9 home health physical therapy visits are not medically necessary. Our physician reviewer found the member was evaluated for physical therapy on 02/20/2020. He had been seen in the Emergency Room 2 days before for severe abdominal pain and fever and had been sent home with a diagnosis of colitis and urinary tract infection. He had a history of a right buttock pressure ulcer being treated by the nursing staff. When evaluated he had significant bilateral lower extremity weakness with strength graded at 3-/5 to 3/5. He had instability when standing and ambulating. There were also impairments in lower extremity range of motion. He had pain rated at 5/10. He had balance deficits and was considered a high fall risk. He required contact-guard assistance for transfers and had significant weakness and instability when ambulating 30 feet from bed to chair. He had a shuffling pattern with an inability to lift his feet during swing phase as he was unable to flex at his knees and hips due to weakness. There were postural deficits noted. The treatment plan included physical therapy to enable him to continue residing at his assisted living facility. The medical information supports that the member is homebound as he is only ambulating 30 feet. He has significant lower extremity weakness and an elevated fall risk. He has a right buttock pressure ulcer consistent with a limited level of mobility and inability to effectively perform pressure relief. His condition would be expected to deteriorate without the skilled services being requested. Physical therapy is indicated and 5 visits were approved. A reassessment after completing the treatments that were authorized would be expected before requesting additional therapy. For these reasons, the remaining physical therapy requested is not considered 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 remaining 9 home health physical therapy (PT) visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 9 home health physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that the Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 the medical services provided on June 24, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Coronary Computed Tomography Angiography (CCTA)
(75574) provided on September 24, 2019.
You asked the Plan to pay for the CCTA. You say that services were medically necessary and billed correctly.
The Plan denied your request. The Plan says the claim is a duplicate of a previously paid claim.
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 75574 is not supported in the medical record. Specifically, without a modifier denoting
a repeat service, the claim remains a duplicate of a previously paid claim. Based on this information, we
decided that Medicare rules for coverage of the CCTA. have not been met. Therefore, we decided that the Plan
does not have to pay for a Coronary Computed Tomography Angiography (CCTA) (75574) provided on
September 24, 2019.