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

We decided that the Plan does not have to pre-approve the Vertiflex procedure (22869).
You asked the Plan to pre-approve the Vertiflex procedure. You say that you can't walk very far and is in lots of pain. You have been waiting and since consult was approved you need to get this procedure done. The Plan denied your request. The Plan says this is considered experimental and investigational and you are not enrolled in an approved clinical study.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and intravenous infusions provided from May 21, 2020, to June 6, 2020.
You asked the Plan to waive the copayments for an inpatient hospital stay and intravenous infusions. You say that you disagree with the charges because you got infections from COVID-19 and inpatient hospital stays. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $390 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You had an inpatient hospital stay from May 21, 2020, to May 31, 2020. Therefore, you are responsible to pay a $390 copayment for days 1-5 (May 21, 2020, to May 25, 2020). $390 (copayment) x 5 (inpatient days) = $1,950. You received intravenous infusion at an outpatient hospital facility from June 1, 2020, to June 6, 2020, for a total of 6 services. Therefore, you are responsible to pay the total allowed amount of $1,335.60, which is less than the total copayment amount. The total amount you owe is: $3,285.60. You have been asked to pay the total copayment amount of $3,285.60 for an inpatient hospital stay and intravenous infusions. An inpatient hospital stay falls within the inpatient hospital care benefit category. Intravenous infusions fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for an inpatient hospital stay and intravenous infusions provided from May 21, 2020, to June 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you strongly recommend these inserts due to the enrollee's condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tracheostomy supplies to be provided by the out-of-network provider.
You asked the Plan to pre-approve the tracheostomy supplies. The Plan denied your request. The Plan says it is not medically necessary to go to an out-of-network provider for tracheostomy supplies. A network gap does not exist.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve tracheostomy supplies to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued usage of a continuous passive motion device.
You asked the Plan to pre-approve continued usage of a continuous passive motion device. You say that you would like to have coverage extended. The Plan denied your request. The Plan says that coverage is limited to that portion of the 3-week period following surgery during which the device is used in the patient's home.
The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week period following total knee replacement surgery during which the device is used in the home. Records show that knee replacement surgery was received on November 25, 2020. The file shows that a CPM device was used for three weeks following this surgery. Therefore, we decided that the Plan does not have to pre-approve continued usage of a continuous passive motion device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services related to a septum repair surgery provided on October 11, 2019 by an out of network (OON) facility.
You asked the Plan to pay for the OON outpatient surgery services. You say that you feel that this should be covered. The Plan denied your request. The Plan says you received this service in an OON facility without prior approval from the plan. There is no evidence that this was an emergency service. As such, this was correctly denied.
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 the outpatient hospital services related to a septum repair surgery provided on October 11, 2019 by an out of network (OON) facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnosis examination (90792) provided June 6, 2019.
You asked the Plan to pay for the psychiatric evaluation. You say that you did not receive proper notice of this enrollee's benefit determination. You depend on the facility for timely notification of patient's health insurance coverage. The Plan denied your request. The Plan says the time limit for filing has expired.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the psychiatric evaluation was not filed until October 16, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychiatric diagnosis examination (90792) provided June 6, 2019.
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 enrollee would benefit from a
LTACH admission. The Plan denied your request. The Plan says this request 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 enrollee does not require services at the LTACH that are not available at the acute
care hospital where he is currently receiving care. Our reviewer found that there are no services available at the
LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. Our
physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Hillrom Volara system (oscillation and lung
expansion therapy).
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show cystic fibrosis, bronchiectasis, or a covered neuromuscular
disease.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
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 a HFCWOD. Our reviewer says that the
requested system is not medically reasonable or necessary. Our physician reviewer found the Volara system is
considered not medically necessary. This system combines oscillating positive airway pressure with
nebulization of medications. Its effectiveness and benefit for patients with COPD has not been established.
There is no rationale for "expansion" therapy in patients with emphysema. You already have a nebulizer.
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 HFCWOD have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Hillrom Volara system (oscillation and lung expansion therapy).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for percutaneous image guided procedures on the spine and spinal cord (01936).
You asked the Plan to pay for the anesthesia. You say that this is a pain management procedure for an epidural injection. This is a payable procedure and should be processed for payment. The Plan denied your request. The Plan says the service does not meet the Medicare criteria for coverage.
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 anesthesia. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 73 year old female diagnosed with lumbar radiculopathy. The provider has requested anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic, which is monitored anesthesia care (MAC) in addition to local anesthesia, during an epidural spine injection. In this case, the clinical documentation did not establish an indication for MAC. The enrollee has an American Society of Anesthesia (ASA ) score of 2 which indicates mild systemic disease, well controlled, without functional deficits and a BMI< 35. The enrollee does not have a history of combative behavior, developmental delay or significant anxiety as an indication for the procedure to be performed under MAC. The anesthesiologist did not provide information to substantiate the use of MAC for this procedure over local anesthesia. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for percutaneous image guided procedures on the spine and spinal cord (01936).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve eight additional acupuncture visits and treatments.
You asked the Plan to pre-approve eight additional acupuncture visits and treatments. You say that the enrollee needs these services. The Plan denied your request. The Plan says that these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 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 eight additional acupuncture visits and treatments. Our reviewer says that the requested services are medically necessary. Our physician reviewer found acupuncture therapy may take multiple sessions to achieve a satisfactory result. The documented 30% improvement is clinically significant. The requested additional therapy is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight additional acupuncture visits and treatments have been met. Therefore, we decided that the Plan has to pre-approve eight additional acupuncture visits and treatments.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has potential to be independent. The Plan denied your request. The Plan says the enrollee does not have an active acute condition that supports physician visits 3 times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for respiratory failure and Covid-19 pneumonia. His medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there is no evidence of any unstable medical conditions requiring daily physician oversight.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for congestive heart failure. His medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 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 pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that skilled nursing is not an appropriate safe level of care at this time. The Plan denied your request. The Plan says the enrollee does not have any acute or new medical conditions.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for management of a humerus fracture, and surgical repair of a hip fracture after a fall. His medical conditions are stable. There are no medical or complex nursing needs requiring inpatient admission. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Superion spacer is not supported in current evidence-based guidelines and peer-reviewed literature over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. The services are considered experimental/investigational in nature and 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 Vertiflex Superion spacer.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lactulose breath test.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not a covered benefit.
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 test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the only test that is covered is a lactose breath hydrogen test to detect lactose malabsorption. The review indicates that there is no specific clinical rationale for the requested lactose breath test. The testing being requested is not for a covered benefit. 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 test have not been met. Therefore, we decided that the Plan does not have to pre-approve a lactulose breath test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the visits to your doctor's office on June 18, 2020 and October 9, 2020.
You asked the Plan to waive the copayments for the office visits. You say that you should only have a $5 copay for these visits. The Plan denied your request. The Plan says office visits with a standard primary care provider have a $20 copay.
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 $20 copayment for a doctor's visit with a standard primary care provider. You have been asked to pay a $20 copayment for the office visits. The office visit was with a standard primary care provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the visits to your doctor's office on June 18, 2020 and October 9, 2020.