Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says that based on Medicare guidelines and the information we have about the enrollee's condition, the enrollee does not meet all the requirements.
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 that the enrollee was admitted to the current acute care hospital with acute respiratory distress related to pneumonia with effusion. He was started on antibiotics prior to the admission for an abscess. The enrollee is using Trach and PEG tube. Weaning difficult over prior months, and he has poor prognosis according to recent assessment. SNF offered but refused. The enrollee appears to not be a good candidate for weaning having failed for months and only requires short term additional acute care hospital services that can safely be received at the current facility until lower level of care services can be obtained. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when treatment has been completed and a more appropriate lower level of care services have been arranged. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orchiectomy for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of an orchiectomy in the setting of low back pain has not been demonstrated in the peer-reviewed literature.
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 requested services are not considered medically reasonable and necessary in this case. The medical records show that the patient has degenerative low back pain with groin pain. There is no indication for orchiectomy. It is not justified as part of the back operation and is purely experimental. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve orchiectomy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine patch.

You asked the Plan to pre-approve Buprenorphine. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit.

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 Buprenorphine patch.

Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that your ankles are swollen, and feet hurt. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided by a participating provider on November 2, 2020, to November 30, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you can't keep paying all these bills for you mother. The Plan denied your request. The Plan says the correct copayments have been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for outpatient rehabilitation services/in-network. The enrollee has been asked to pay a $35 copayment for each outpatient rehabilitation services. The total amount you are being asked to pay is $295.68 which is less then your copayment amount of $315 ($35 x 9 visits = $315). Outpatient rehabilitation services fall within the outpatient rehabilitation services/in-network benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided by a participating provider on November 2, 2020, to November 30, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a bilateral Duplex scan of the arteries of the legs.
You asked the Plan to pre-approve the arterial Duplex scan. You say that it is felt that the enrollee requires this imaging at this time. The Plan denied your request. The Plan says that the enrollee does not need to have this service until one year has passed since their original procedure.
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 the arterial Duplex scan. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found on October 27, 2020 the patient was identified to have a patent femoral-femoral artery bypass graft with elevated velocities in the inflow external iliac artery. Additionally, elevated velocities were noted at the left anastomosis. These findings require closer surveillance than yearly. If the patient develops worsening of the stenosis and is not detected in time, the stenosis could become graft threatening and lead to graft failure. Follow-up at 6 months under these conditions is both reasonable and 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 arterial Duplex scan have been met. Therefore, we decided that the Plan has to pre-approve a bilateral Duplex scan of the arteries of the legs.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pelvic surgery (58661).
You asked the Plan to pre-approve pelvic surgery. You say that this requested surgery is medically necessary. The Plan denied your request. The Plan says surgery to reshape normal structures of the body is not covered.
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 pelvic surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has failed medical management and declines further medical management of endometriosis due to the exacerbation of anxiety and depression. Therefore, if endometriosis exists, it may be reasonable to treat with bilateral oophorectomy balancing the risks and benefits of ovary removal. However, the diagnosis of endometriosis needs to be established laparoscopically which was the initial plan. The plan is very clear that they do not pay this type of surgery if it is solely being performed for de-feminization of a transgender male. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pelvic surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve pelvic surgery (58661).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional trips. You say that you need the extra rides because you are a dialysis patient and goes 3 times a week. You need more rides to continue your treatment. The Plan denied your request. The Plan says this request exceeds the maximum benefit allowed.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
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 the enrollee's ongoing skilled therapy and nursing 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 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis of the toe. You
had amputation of the affected toe. Your medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel.

We looked at the file and Medicare rules. As the services in question were part of a panel, it is inappropriate to bill multiple codes for the panel. 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 the lab services provided on November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lumbar spine (72148).
You asked the Plan to pre-approve the MRI. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says guidelines do not support the use of serial detailed picture studies for the surveillance of healing or recovery from spinal disease in the majority of spinal disorders.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee had a lumbar MRI in 2020. There is no documentation of a significant change in symptoms. A new lumbar MRI not medically needed. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lumbar spine (72148).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a ventilator (E0466).
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee could be treated with BiPAP.
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 ventilator. Our reviewer says that the criteria for coverage of a ventilator have been met. Our physician reviewer found the enrollee has chronic respiratory failure consequent to COPD. BiPAP has been ruled out as an effective means of providing adequate respiratory improvement. The enrollee's pulmonologist documents that the enrollee requires chronic nocturnal intermittent positive pressure ventilation for treatment of chronic hypercapnia due to COPD, in order to reduce the morbidity of disease including to reduce exacerbations of chronic disease, hospitalizations, and potential mortality. 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 ventilator have been met. Therefore, we decided that the Plan has to pre-approve a ventilator (E0466).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5284 x 2).
You asked the Plan to pre-approve the dental service. You say that the enrollee needs these services. The Plan denied your request. The Plan says removable unilateral partial dentures are not listed as covered services.
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. Therefore, we decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5284 x 2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on May 8, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation does not support 15-21 drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on May 8, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on December 17, 2020.
You asked the Plan to pay for the nursing facility visit. You say that the attached documentation supports payment of the billed code. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 nursing facility visit provided by an out-of-network provider on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the office visit with a specialist (99213), comprehensive hearing test (92557) and tympanometry test (92567) provided on January 19, 2021.
You asked the Plan to waive the cost-share for the office visit and diagnostic hearing tests. You say that this was a routine hearing exam which should have a $0 copayment. You say the Plan told you that you should have seen a provider in the routine hearing benefit network, but this information is not listed in the coverage information. The Plan denied your request. The Plan says these tests were performed by a medical professional and were billed as diagnostic tests, not a routine screening. You pay a $40 copayment for an office visit with a specialist and 20% coinsurance for Medicare-covered diagnostic tests and procedures. These claims applied correctly.
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 $40 copayment for an office visit with a specialist and 20% coinsurance for Medicare-covered diagnostic tests and procedures. You have been asked to pay $40 for the office visit with a specialist and 20% coinsurance for the diagnostic hearing tests. The hearing tests provided were billed as diagnostic services and were not received from a provider in the Plan's specified routine hearing network. Routine exams are performed when there is no cause
for concern or symptoms of a problem, whereas diagnostic tests are provided to investigate potential issues. The hearing tests you were provided fall into the Medicare-covered diagnostic tests and procedures 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 cost-share for the office visit with a specialist (99213), comprehensive hearing test (92557) and tympanometry test (92567) provided on January 19, 2021.