Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting. The LTACH will not provide additional services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you live alone and are not able to care for yourself. The Plan denied your request. The Plan says you are medically stable and have no skilled care needs. 
 
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 physician reviewer found that from a nursing perspective, you had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are able to transfer with supervision to minimal assistance. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on March 16, 2020 by a nonparticipating
provider.
You asked the Plan to pay for the hearing aids. You say that the stay was medically necessary. The Plan denied
your request. The Plan says your contract states that you must call the supplemental hearing plan to schedule an
appointment in order to utilize the hearing aid benefit. The Plan states they have been in contact with the
supplemental hearing plan who confirmed that they did not have an account on file for you.
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.
Review of the file show that you purchased the hearing aids on March 16, 2020 by a non-participating
provider. Your EOC states, you must see a supplemental hearing plan provider to use this benefit. 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/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 hearing aids purchased on March 16, 2020 by
a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living facility services provided on April 30, 2020
by an out of network (OON) provider.
You asked the Plan to pay for assisted living facility services. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was
not obtained. The Plan says that the referring facility is also out-of-network.
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 has network providers
available who can provide 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 assisted living facility services provided on April
30, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you were discharged
from the hospital following a triple bypass surgery. You say that the discharge instructions require that you
test/monitor your blood pressure daily. The Plan denied your request. The Plan says the item in dispute is not
covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit provided on January 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for a rest home visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers available who can provide 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 a rest home visit provided on January 6, 2020 by an out of network (OON) provider.
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 the enrollee does not require an interdisciplinary approach with multiple specialist to oversee rehab 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 physician reviewer found that the enrollee suffered multiple injuries, including multiple bony fractures and a closed head injury, with intraparenchymal and subdural hemorrhages, in a motor vehicle crash. Mechanical ventilation and a tracheostomy were required for respiratory failure. She is now off mechanical ventilation. The progress note documents that the enrollee had moderate agitation. Her chest X-ray showed a pleural effusion and pneumonia. It has not been demonstrated whether the effusion is free- flowing and whether a thoracentesis will be needed. The documentation supports that the enrollee requires a higher level of care than an IRF can provide at this time. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The documentation raises significant concerns about whether the enrollee is able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator. 
 
You asked the Plan to pre-approve a non-invasive home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 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 non-invasive home ventilator. Our reviewer says that the documentation does not support that the requested non-invasive home ventilator is medically reasonable or necessary. Our physician reviewer found the enrollee has COPD with recent hospitalizations for exacerbations. The pCO2 was elevated during the most recent admission, but there is no ABG data with the patient in a stable state as an outpatient. BiPAP has not been tried and demonstrated to have failed. Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP machines can provide the AVAPS-AE mode of support that is ordered. Therefore, the requested item is 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 a non-invasive home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive home ventilator
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 IRF care would give the enrollee the best chance for optimal functional gain. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. 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 you need strength to walk on your own. The Plan
denied your request. The Plan says you do not require frequent physician management, or an interdisciplinary
approach to rehab 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 physician reviewer found
that you were admitted to the hospital for a video-assisted thoracoscopic surgery (VATS) pericardial window
for a pericardial effusion. You are generally medically stable. The documentation does not support that he has
complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician
three times per week. While you may well benefit from continuing physical and occupational therapy, the
documentation does not support that there is need for an intensive therapy program with therapy 3 hours per
day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an MRI scan. Our reviewer says that
the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician
reviewer found the enrollee severe right shoulder pain. The enrollee was found to have limitations in range of
motion of the right shoulder and observed some improvement with a home conditioning program (physical
therapy) but not from medications. The enrollee was able to abduct past 180 degrees, but had a positive empty
can test. MRI right shoulder was requested. The enrollee had been diagnosed with bursitis in the past, however,
the details of a full right shoulder examination were not detailed in the notes to help determine if this was likely
bursitis, tendinitis, arthritis, or a more severe rotator cuff injury or other red flag diagnosis. The documentation
supports that therapy was helping. The records did not show that x-ray had been completed for the most recent
complaints which would help rule out other conditions. MRI does not appear to be appropriate or warranted at
this time based on the above factors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve an MRI scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on December 11, 2019. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids must be supplied by the Plan's hearing network vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when supplied by the Plan's hearing network vendor. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not supplied the Plan's hearing network vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that the requested lumbar epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested lumbar epidural steroid injection.
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 a lumbar epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for the requested lumbar epidural steroid injection. Our physician reviewer found this enrollee presents with chronic grade 8-9/10 low back pain radiating into the buttocks, the right hip, and down the left lower extremity to just below the knee. Functional limitations are noted in activities of daily living. She is status post L3/4 fusion in 2015. She has reportedly been recommended for L3-S1 laminectomy and fusion with previous hardware removal. She underwent a right L4-S1 transforaminal epidural steroid injection on 12/9/19 with 20% pain reduction that lasted for one to two weeks. She underwent a left L4/5 and L5/S1 transforaminal epidural steroid injection on 5/12/20 with 40-50% improvement in pain symptoms that lasted for 6-7 days. Under consideration is a request for lumbar epidural steroid injection. Medicare coverage criteria have not been met. There is no evidence that the enrollee showed significant improvement after the prior injections to support a repeat procedure. Therefore, this enrollee does not have a covered indication for the requested lumbar epidural steroid injection. 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 lumbar epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin lesion trimming procedure provided on February 11, 2020.
You asked the Plan to waive the copayment for the skin lesion trimming procedure. You say that you were only there 5 minutes and are being charged too much. 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 $350 copayment per date of services at an outpatient hospital facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the skin lesion trimming procedure.
You have been asked to pay a $177.58 copayment for the skin lesion trimming procedure. The skin lesion trimming procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the skin lesion trimming procedure is considered a surgical procedure.
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 skin lesion trimming procedure provided on February 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 9,
2020.
You asked the Plan to waive the copayment for emergency care. You say that a home health aide told you to go
to the emergency room after taking your vitals but the emergency room said that you were fine and sent you
home. 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
care 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 emergency care provided on
March 9, 2020.