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

We decided that the Plan has to pay for the orthopedic follow-up and shoulder x-ray provided out of area on
February 21, 2020.
You asked the Plan to pay for the orthopedic visit and x-ray. You say that you were told that you needed to be
seen 3 days after your initial injury treatment and were able to be seen by this provider prior to returning to the
service area. You state you were not able to get an appointment elsewhere for a week or more. The Plan denied
your request. The Plan says that this was not an urgent medical condition and the services were available from
a network provider in the service area.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and
pre-approved care.
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 orthopedic visit and x-ray. Our reviewer
says that the services provided are medically necessary and are considered urgently needed out of area care.
Our physician reviewer found the enrollee suffered a non-displaced fracture of the neck of her left humerus on
2/14/20. She was seen in follow-up by one week later, before returning to her home state. The enrollee reported
9/10 pain at worst. It would not have been reasonable to delay orthopedic follow-up longer than one week. The
enrollee reported severe pain. Orthopedic follow-up was urgently needed, and was medically reasonable and
necessary prior to return to her service area, to determine whether fracture alignment was maintained.
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 orthopedic visit and x-ray have been met. Therefore, we decided that the
Plan has to pay for the orthopedic follow-up and shoulder x-ray provided out of area on February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for replace broken teeth - per tooth (D5640) provided to the enrollee February 3, 2020 through February 10, 2020.
You asked the Plan to pay for the dental services. You say that no dental coverage does not make sense because all of the patient's insurance cards state Medicare dental. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for replace broken teeth - per tooth (D5640) provided to the enrollee February 3, 2020 through February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (K0823).
You asked the Plan to pre-approve the power wheelchair. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan states their consultant checked you in your home and saw that you can get around in your apartment and take care of yourself using a walker and a cane. The Plan states that your home is too cluttered to use a wheelchair in it. The Plan states that Medicare will only pay for this if you need it to take care of yourself in your home. The Plan further states that the consultant said you only use the wheelchair you have to go outside of your apartment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. You are able to ambulate around your living space with a walking stick/cane in the space itself because it is too cluttered for a power wheelchair. The power chair predominantly is used outside the home only and therefore becomes a convenience issue. Medicare does not allow for convenience issues. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator with humidifier.
You asked the Plan to pre-approve a home ventilator with humidifier. You say that the requested home
ventilator with humidifier is medically necessary. The Plan denied your request. The Plan says the enrollee
does not meet criteria for the requested home ventilator with humidifier.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 home ventilator with humidifier. Our
reviewer says that the enrollee does not meet criteria for the requested home ventilator with humidifier. Our
physician reviewer found coverage criteria for a home ventilator are not met. The records indicate a diagnosis
of chronic obstructive pulmonary disease (COPD), but there are no supporting clinical data, such as pulmonary
function tests. The order indicates the ventilator is to treat obstructive sleep apnea (OSA), but there is no
documentation of that diagnosis, and no documentation of failure of CPAP or BiPAP. Medicare does not cover
a home ventilator for the treatment of OSA, or when used as a BiPAP device. There is no documentation of
hypercarbia, with an arterial blood gas while in a stable state. A home ventilator is not medically necessary in
this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home ventilator with humidifier have not been met. Therefore, we decided
that the Plan does not have to pre-approve a home ventilator with humidifier.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says the scan is not covered for surveillance purposes.
The Plan must follow Medicare rules. Medicare rules say that PET 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 was correct in denying the request to pre-approve a PET scan. Our physician reviewer found that PET scans are indicated for restaging or to determine diagnostic or treatment strategies. This PET scan is being ordered for chest pain to look for occult findings. There is no imaging of chest by a CT; just abdomen and pelvis with incomplete view of chest. Therefore, the requested PET scan is not 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 a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for additional reimbursement for resin-based composite - two surfaces, posterior (D2392) provided on January 6, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you exhausted your benefit allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. You have a $75 maximum benefit for comprehensive dental procedures, including fillings. Additional reimbursement beyond $75 for a filling is not a covered benefit under your supplemental dental plan. Therefore, we decided that the Plan does not have to pay for additional reimbursement for resin-based composite - two surfaces, posterior (D2392) provided on January 6, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered item, per Medicare guidelines.
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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the enrollee has idiopathic pulmonary fibrosis and hypoxemia during exercise. The O2 saturation drops below 86% during activity, and therefore the patient does qualify for home oxygen supplementation and portable oxygen to maintain mobility within the home. But Medicare does not specify the equipment to be provided for portable oxygen. Usually this is in the form of portable compressed oxygen tanks, or a liquid oxygen system. A portable oxygen concentrator is generally used for oxygen supplementation outside the home or when traveling, which is not covered by Medicare. A portable oxygen concentrator is 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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for infectious agent disease testing provided on March 10, 2020.
You asked the Plan to pay for infectious agent disease testing. You say that you only perform this test in your hospital laboratory. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.
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 pay for infectious agent disease testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this testing was performed in a laboratory and was indicated for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infectious agent disease testing have been met. Therefore, we decided that the Plan has to pay for infectious agent disease testing provided on March 10, 2020.
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 admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.
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 is currently undergoing treatment at an ACH for respiratory failure and
sepsis. The enrollee has a tracheotomy at baseline. She was placed on a ventilator, but has since been weaned
to a tracheotomy collar. Here appears to be no expectation of decannulation. There is no evidence that the
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the
same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at
the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged
to a lower level of care for any ongoing long term care needs.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as the enrollee was not a danger to themselves or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment plan found in the record. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 12, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 28,
2019 through October 30, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on October 28, 2019 and discharged on October 30, 2019.
You were asked to pay a $310 copayment per day from October 28, 2019 through October 29, 2019, days 1-2
of your inpatient hospital care. You were discharged on October 30, 2019 and there was no copayment charge
for the day of discharge. Per your contract there is a $310 copayment per day for days 1-6 for inpatient hospital
care. 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 inpatient hospital care from October 28, 2019 through
October 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant.
You asked the Plan to pre-approve Dexilant. You say that the enrollee has been on Dexilant for years. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition by the Part B plan.
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.
Benefits for Dexilant may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your therapy needs can be provided at a lower level of care.
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. You are medically stable with no evidence of need for supervision by physical medicine and rehab physician or need acute rehab nursing care. Functionally given your current level, you do not require IRF level of therapies. You may benefit from further physical therapy and occupational therapy but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs more therapy. The Plan
denied your request. The Plan says that the member does not require the daily skilled therapy or nursing
services.
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 pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac catheterization procedure
provided from November 12, 2019 to November 13, 2019.
You asked the Plan to waive the copayment for the cardiac catheterization. You say that you were told you
were fully covered and had no expenses. You say you were to be discharged prior to the second day but were
not released until November 13, 2019. 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 $150
copayment for each visit to an outpatient hospital facility.
You have been asked to pay a $150 copayment for the cardiac catheterization. The cardiac catheterization falls
within the "Outpatient surgery, including 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 copayment for the cardiac
catheterization procedure provided from November 12, 2019 to November 13, 2019.