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

We decided that the Plan does not have to pre-approve an expandable controller (CPT E2311, E2377, and E2313).
You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is a critical part for the functioning of the power chair. You say that you need the expanded controller system in order to properly operate all of the functions that the chair has. You say that you have issues with your shoulders, are in a lot of pain, and have been getting infections from your current chair. You say that all of the items being requested are needed in order to maintain a current level of function. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for an expandable controller because there appears to be sufficient arm and hand function to use the switches.
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 expandable controller. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion] 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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (CPT E2311, E2377, and E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.
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 the medical services provided on August 16, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transthoracic Echocardiography (TTE).
You asked the Plan to pre-approve a TTE. 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 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 a TTE. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of remote smoking, gastric reduction surgery, Chiari malformation and chronic headaches. An echocardiogram January 26, 2016 reported normal ventricular function and no valve disease. A clinic note dated December 18, 2017 documents no cardiac symptoms and a normal cardiac physical exam with a repeat echo that day reporting no change and no evidence of vegetation. A clinic note dated May 26, 2020 documents orthostatic hypotension and a normal cardiac physical exam. The documentation supports that the enrollee has orthostatic hypotension, a normal cardiac physical exam and two prior normal echocardiograms. Therefore, the enrollee does not meet criteria for the requested 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 a TTE have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transthoracic Echocardiography (TTE).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.
You asked the Plan to pre-approve Xarelto. You say that the enrollee is stable on the medication samples. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Xarelto.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January 20, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that you cannot find anywhere in the Evidence of Coverage that says there will be a copayment for the eye exam. 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 $10 copayment for Medicare-covered physician services. You have been asked to pay a $10 copayment for the medical eye exam. The medical eye exam falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows diagnosis of cataracts which makes the eye exam medical in nature.
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 medical eye exam provided on January 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Gel.
You asked the Plan to pre-approve Diclofenac Gel. You say that the enrollee has been stable on medication. The Plan denied your request. The Plan says Diclofenac Gel to be taken at home is not covered under the Part B 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 Diclofenac Gel.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 11, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you felt better when you got to the ER but was informed you should take a test. You say that the ER copayment shouldn't be $90. The Plan denied your request. The Plan says the copayment 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 $90 copayment for each emergency care visit within the United States. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided on January 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) and adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on November 13, 2019.
You asked the Plan to pay for the bitewings and adjunctive pre-diagnostic test. You say that you believe the enrollee took the appropriate measures to find an in-network provider. The Plan denied your request. The Plan says these services are not covered by 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. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) and adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided on November 13, 2019.
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 medical necessity has not been established. Therefore, 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status and chronic medical conditions do not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you want to appeal the Plan's denial of the orthotics because they are medically necessary for you. You say that you have worn orthotics to successfully deal with the pain of your plantar fasciitis for several years. You stated that your old pair had worn out and your podiatrist prescribed new ones for you. You say that you thought your insurance would cover them and it would be a financial hardship for you to have to pay for them by yourself. 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 pay for foot orthotics.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for Home Health services provided on January 9, 2019 through March 8, 2019.
You asked the Plan to pay for the Home Health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment is not appropriate for the HIPPS codes billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to forward information to identify what procedure codes are at issue and why the HIPPS code submitted is inappropriate. There is insufficient documentation to substantiate the Plan's denial of these services. Therefore, we decided that the Plan has to pay for Home Health services provided on January 9, 2019 through March 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. 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 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has NYSHA Class III congestive heart failure with reduced ejection fraction (LVEF 30%) requiring hospitalization. In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 15, 2020.
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 the testing is 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 January 15, 2020.
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 the services required by the enrollee exceeds the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee's needs are being met in the acute setting.
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 physician reviewer found that the enrollee presented to the acute hospital with worsening right sided weakness and speech difficulties. Work-up revealed a new acute left frontoparietal non-traumatic intracerebral hemorrhage. He was intubated for airway protection, and underwent surgical evacuation of the intracerebral hematoma. He has since been encephalopathic with seizure activity and functional quadriparesis. The acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 16, 2018 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the office visit was self-referred. The Plan says that no prior authorization was 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 genetic testing provided on September 16, 2018 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 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 based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate 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 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.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is currently in-house and is losing out on services because the denial of SNF care. You say that the enrollee is receiving physical therapy and occupation therapy and needs these services to improve her health. The Plan denied your request. The Plan says the records do not show a need for daily skilled therapy or daily skilled nursing care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was alert and oriented, and was mobility with study gait. The enrollee's lungs were clear and she was monitored for COVID infection. There is no documentation that the enrollee received or required any skilled therapy. There is no identifiable skilled nursing service need. There is no identifiable skilled therapy service need. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the external mobile cardiovascular telemetry with electrocardiographic recording (93229, 93228) provided on October 30, 2019.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered non-radiological diagnostic services. You have been asked to pay a $130.34 coinsurance (20% x $651.71 allowed amount) for the Medicare-covered non-radiological diagnostic service provided. 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 coinsurance for the external mobile cardiovascular telemetry with electrocardiographic recording (93229, 93228) provided on October 30, 2019.