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

We decided that the Plan does not have to pre-approve an oxygen concentrator (HCPCS E1390).
You asked the Plan to pre-approve the concentrator. You say that the plan should urgently approve the
therapies the physician has ordered. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that only a stationary gaseous oxygen system (E0424)
and related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a
clinical trial approved by CMS.
There is no evidence of enrollment in a clinical study. Additionally, this is not type of oxygen system covered
for treatment of cluster headaches. 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 an
oxygen concentrator (HCPCS E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 7, 2019 to May 8, 2019.You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says observation care could have been provided.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The enrollee's condition improved with treatment and she was felt stable for discharge the following day without patient follow-up. She did not require two midnights in the hospital 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 7, 2019 to May 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for an out-of-network (OON) eye exam (90215)
provided on September 5, 2019.
You asked the Plan to pay the full amount for an OON eye exam. You say that you did not know this provider
was not in-network with your vision plan.. The Plan denied your request. The Plan says this claim processed
correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services up to $75. When using an out-of-network provider, you will be
responsible for costs above the plan approved amount.
We looked at the file and the Plan's rules. The records show that you have been reimbursed $75 for the eye
exam at issue. This means that the Plan has paid the correct amount according to the EOC. Based on this
information, we decided that the Plan's rules for coverage of an OON eye exam have not been met. Therefore,
we decided that the Plan does not have to pay the full amount for an out-of-network (OON) eye exam (90215)
provided on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on May 15, 2019.
You asked the Plan to pay for the assistant surgeon services. The Plan denied your request. The Plan says this
type of provider is not payable for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services
provided on May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on December 3, 2019. You asked the Plan to waive the copayment for a CT scan. You say that you were not informed that you would owe a copayment. 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 $200 copayment for diagnostic radiology services. You have been asked to pay the allowed amount of $161.67, which is less than the $200 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a CT scan provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation of pre and post basic therapy leg measurements.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lymphedema of the lower extremities, but no truncal or abdominal extension is documented in the physical exam. There is no sufficient documentation of unique characteristics described that would indicate the segmented pump over a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device for the enrollee.
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 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 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 was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on her medical stability and low endurance. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) provided on August 28, 2019.You asked the Plan to pay for needle electromyography. You say that the operative report shows this code is appropriate.The Plan denied your request. The Plan says there is no documentation of this code being performed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters.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 needle electromyography. Our reviewer says that CPT 95870 is not supported by the submitted records. Our physician reviewer found the medical records provided do not include documentation of a Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters being performed on August 28, 2019.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography (95870) provided on August 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a SNF for rehabilitation.
You asked the Plan to pre-approve the SNF admission. You say that you need to strengthen yourself to go up and down before you go home because you live alone. The Plan denied your request. The Plan says the medical records do not support the skilled nursing services of physical therapy with the ability to transfer independently and able to walk short distances of 30 feet with supervision or front wheel walker.
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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 pre-approve the admission to a SNF for rehabilitation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea duplex scan of the heart and blood vessels for the enrollee.
You asked the Planto pre-approvethe study. You say that this is medicall ynecessary.The Plandenied your request. The Plansaysthis is 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 the study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has known severe vascular disease, but no documented symptoms or findings of current vascular insufficiency and lung cancer being palliated with chemotherapy and radiation. Since there are no documented symptoms or findings of current vascular insufficiency and there is documented life limiting malignancy, the records do not support the medical necessity for a Duplex scan of the heart and blood vessels. Criteria are not met since there are no documented signs or symptoms required for coverage of the 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 the study have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea duplex scan of the heart and blood vessels for the enrollee
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 29, 2019 to August 1, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says that inpatient admission was not ordered by the hospital.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on July 29, 2019 after a ground level fall and complaining of dizziness. She was treated with IV fluid and admitted. She was evaluated by Neurology and Endocrinology. She underwent magnetic resonance imaging of the brain. She was also placed on the alcohol withdrawal protocol. She became increasingly agitated and hallucinating requiring Ativan and skilled nursing facility placement was recommended. She was felt stable for discharge on August 1, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 29, 2019 to August 1, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued care and treatment with an out-of-network addiction medicine/internal medicine specialist.You asked the Plan to pre-approvecontinued care and treatment. You say that the requested continued care and treatment with the out-of-network provider is medically necessary.The Plan denied your request. The Plan says the requested continued care and treatment with the out-of-network provider is not medically necessary.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 pre-approve continued care and treatment. Our reviewer says that the requested continued care and treatment with the out-of-network provider is not medically necessary. Our physician reviewer found the enrollee is with a past medical history of chronic back pain, osteoarthritis and anxiety who is seeing an out-of-network specialist for treatment of chronic pain and opioid dependence with Suboxone. At issue is the necessity of continued treatment with the out-of-network provider. The review shows that nothing in the provided medical records indicates that the enrollee cannot get appropriate care for his conditions from an in-network provider. Nothing in the provided medical records indicates there is anything unique about this enrollee's condition that would make it medically necessary for him to continue care with the out-of-network specialist. The Plan has shown that they have in-network addiction medicine specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. This enrollee's medical management and/or follow-up care can be safely transitioned to an in-network addiction medicine specialist 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 continued care and treatment havenot been met.Therefore, we decided that the Plan does not have to pre-approvecontinued care and treatment with an out-of-network addiction medicine/internal medicine specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (CPT 96372 and HCPCS J0717) provided to the enrollee on September 18, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: CPT 96372: therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular HCPCS J0717: Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered); 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is no evidence that the enrollee received an injection of Cimzia on 9/18/2019. Therefore, the billing of CPT 96372 and J0717 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (CPT 96372 and HCPCS J0717) provided to the enrollee on September 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transportation trips.
You asked the Plan to pre-approve transportation trips. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 24, 2019 to December 31, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated in observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found while the enrollee spent two midnights in the hospital, at the time of admission, it was not reasonable to expect that two midnights of inpatient level care would be medically necessary. The enrollee suffered a mechanical fall resulting in non-operable fractures. There is no documentation of uncontrolled co-morbidities or complications, necessitating a prolonged (i.e. two midnight) stay. The enrollee required pain control and placement, which could have been accomplished 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 24, 2019 to December 31, 2019.