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

We decided that the Plan does not have to pay for the portable imaging services provided on August 5, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, the services were billed with Place of Services (POS) code 31. POS code 31 would indicate that the enrollee was in a Part A covered stay. If that were the case, then the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the portable imaging services provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are
no required medical services identified that are available at the LTACH, that are not available at the current
health care setting being offered by the health plan. Consequently, the requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 home health physical therapy visits.
You asked the Plan to pre-approve 16 home health physical therapy visits. You say that the requested 16 home health physical therapy visits are medically necessary. The Plan denied your request. The Plan says the requested 16 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 16 home health physical therapy visits. Our reviewer says that the requested 16 home health physical therapy visits are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment and that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. Based on the available records the enrollee appears to have improved with therapy to the point of being able to walk 200 feet with a rolling walker with supervision and she is supervision to contact guard assist for transfers. Further utilization of the home exercise program appears appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 16 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 home health physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the knee you had on December 3, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you do not believe that you should have to pay this copayment. You say that your plan required you to get this CT scan because you could not have an MRI due to having a neurostimulator. You said that the CT scan wasn't the appropriate test to assess a meniscal tear, so you should not have to pay for it. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the CT scan ($185.90) is less than your copayment obligation, you are responsible for the full billed 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 $200 copayment for outpatient hospital radiology services. You have been asked to pay a $200 copayment for the CT scan. The CT scan falls within the outpatient hospital radiology services 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. This copayment applies regardless of the reason for the test. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the knee you had on December 3, 2020.
Your complaint about the Plan's requirement that you have this CT scan 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. In addition, in your letter sent directly to us you indicated that you are also asking for the Plan to waive cost sharing for other pre-operative testing. You will need to contact your plan directly to begin the appeals process for those services as this case only addresses the CT scan referenced above.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen panel (0100U) provided on August 31, 2020.
You asked the Plan to pay for the respiratory pathogen panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.
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, the respiratory pathogen 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 respiratory pathogen panel (0100U) provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an LSO (L0637) received on February 19, 2020.
You asked the Plan to waive the coinsurance for an LSO. You say that the supplier is overcharging you. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered durable medical equipment. You have been asked to pay $236.60, or 20% of the Medicare-allowed amount of $1,182.99, for an LSO. Aan LSO falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an LSO (L0637) received on February 19, 2020.
Your complaint about the supplier overcharging the Plan 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the thoracic spine.
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that the requested MRI of the thoracic spine is medically necessary. The Plan denied your request. The Plan says the requested MRI of the thoracic spine is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 was correct in denying the request to pre-approve an MRI of the thoracic spine. Our reviewer says that the requested MRI of the thoracic spine is not medically necessary. Our physician reviewer found the enrollee is with periscapular thoracic back pain. Criteria for MRI have not been met. There is no documentation of adequate conservative measures to include physical therapy. There are no red flags documented to show the need of the requested MRI 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 an MRI of the thoracic spine have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the thoracic spine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing you received on November 16, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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, the COVID-19 test, 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 COVID-19 testing you received on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.
You asked the Plan to pre-approve Tadalafil. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Tadalafil.
Benefits for Tadalafil 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: 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 it is not medically reasonable and necessary to provide these skilled nursing or skilled therapy services on a "daily basis". You do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertiflex superion device.
You asked the Plan to pre-approve vertiflex superion device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 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 pre-approve vertiflex superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. The Vertiflex device is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 vertiflex superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve vertiflex superion device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the Urolift procedure.
You asked the Plan to pre-approve Urolift. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this procedure is correct, because the enrollee has not tried and failed - or had a contraindication to - 3 months of conventional medication therapy.
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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Urolift. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found guidance indicates that Urolift may be offered to patients with benign prostatic hypertrophy with lower urinary tract symptoms, with a prostate volume of less than 80 grams, and who are devoid of an obstructive middle lobe. In particular, it may be offered to eligible patients concerned about erectile and ejaculatory functions. The enrollee is an appropriate candidate for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Urolift have been met. Therefore, we decided that the Plan has to pre-approve the Urolift procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from June 22, 2020, to July 1, 2020.
You asked the Plan to pay for the SNF admission. You say that the SNF admission was medically necessary. The Plan denied your request. The Plan says that the SNF care is not medically necessary. The Plan also says that the services needed could have been performed at a lower level of care.
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 pay for the SNF admission. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from June 22, 2020, to July 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Memantine.
You asked the Plan to pre-approve Memantine. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Memantine.
Benefits for Memantine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Farxiga.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Evenity. Our reviewer says that the criteria for coverage of Evenity have not been met. Our physician reviewer found there is no documentation of a trial and failure of bisphosphonates. There is no documented contraindication to bisphosphonate use. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity (J3111).