Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services
provided from September 12, 2020, through September 24, 2020.

You asked the Plan to pay for the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says the SNF services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She had uncomplicated wound care. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a supervision to contact guard assist level with functional mobility including gait to 45 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 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 pay for continuation of SNF services provided from September 12, 2020, through
September 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology testing provided on February 5, 2021.

You asked the Plan to pay for the services provided. You say that you should have been advised the provider was not in your network. The Plan denied your request. The Plan says that care was available from a network provider.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the services by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the pathology testing provided on February 5, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on February 26, 2021.

You asked the Plan to waive the coinsurance for DME. You say that the DME was not necessary and made the
provider pick it back up. You state that the box was never opened and the charges are fraudulent. 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 20%
coinsurance for DME and related supplies.

The record shows that you received DME on February 26, 2021. Therefore, you are responsible to pay your
share of the cost-sharing charges. The allowed amount is $13.37 and 20% of that is $3.34.

You have been asked to pay the total coinsurance amount of $3.34 for DME. DME falls within the DME and
related 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 coinsurance for DME provided on February 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.

You asked the Plan to pre-approve PET scan. You say that this test is needed so that your doctor can make an informed diagnosis about your condition. The Plan denied your request. The Plan says the denial of authorization for this PET scan is correct, because you have not had testing showing cognitive impairment.

The Plan follows Medicare rules. Medicare rules state that PET scans may be used for enrollees who meet criteria for both Alzheimer's Disease and Frontotemporal Dementia but the cause of the clinical symptoms remains uncertain. 

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 PET scan. Our reviewer says that you do not meet the Medicare criteria for this PET scan. Our physician reviewer found a PET scan for the evaluation of dementia may be covered to differentiate between patients who meet criteria for both Alzheimer's Disease (AD) and Frontotemporal Dementia (FTD). There are other requirements which must also be satisfied. In this case the records provided do not show that you meet diagnostic criteria for either AD or FTA - let alone both conditions. Therefore, this service would not be 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance image-guided high intensity focused utlrasound (MRgFUS) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee is an inappropriate candidate for deep brain stimulation.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided for review are also otherwise not sufficient to determine if she has any of the contraindications to the procedure (or a non-covered indication). For these reasons the criteria for coverage would not be met. 

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 pre-approve magnetic resonance image-guided high intensity focused utlrasound (MRgFUS) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for an ultrasound of the heart (93306) provided on October 22, 2020.
You asked the Plan to waive the cost-shares for an ultrasound of the heart. You say that you already met your deductible by the date on this claim and you do not know why you must pay the full amount of the service. The Plan denied your request. The Plan says the cost shares you are being charged are correct.
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 $500 deductible for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that after you pay your $500 deductible, you pay a $160 copayment for each outpatient diagnostic tests and therapeutic services and supplies including an ultrasound. You have been asked to pay $104.88 towards your deductible and a $75.63 copayment for an ultrasound of the heart. At the time this claim was processed, you had met $395.12 of your $500 deductible. The remaining deductible amount of $104.88 was assessed ($500 - $395.12 = $104.88). The Medicare allowed amount for this service is $180.51. Since you had not reached your deductible, this left a remaining amount of $75.63 ($180.51 - $104.88 = $75.63).
You were then asked to pay a $75.63 copayment for outpatient diagnostic services, which is lower than your copayment of $160 per the EOC. Your total cost share obligation is therefore $180.51. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible and a $160 copayment for each outpatient diagnostic tests and therapeutic services and supplies including an ultrasound, after the deductible is met. 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-shares for an ultrasound of the heart (93306) provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0673).

You asked the Plan to pre-approve the device. You say that this has been recommended to prevent blood clots following surgery. The Plan denied your request. The Plan says the medical records do not indicate any lymphedema or venous insufficiency with ulcers.

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 documentation does not indicate a diagnosis of persistent chronic and severe lymphedema or a failure of a four week trial of conservative therapy. The criteria is not met. 

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 pneumatic compression device (E0651, E0673).
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 you can no longer drive, you have high arches, and use a walker. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite blood glucose test strips.

You asked the Plan to pre-approve Freestyle Lite blood glucose test strips. You say that these requested test strips are medically necessary. The Plan denied your request. The Plan says there is no medical reason why the enrollee cannot use the Plan's preferred brand.

The Plan follows Medicare rules. Medicare rules say that the Plan may specify certain brands as preferred brands as long as certain conditions are met. 

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 Freestyle Lite blood glucose test strips. Our reviewer says that the requested Freestyle Lite test strips are not medically necessary. Our physician reviewer found there is no treason given why the patient cannot use the Plan's preferred brand One Touch products and why she needs to use the Freestyle Lite system for monitoring her levels. If this data is available, it should be submitted and the case re-reviewed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle Lite blood glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite blood glucose test strips.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for left sacroplasty for a sacral fracture. Medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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. 

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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT
code 22869).

You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan
denied your request. The Plan says there are not enough scientific studies to show that inserting a device to
open the narrowed space would be safe and effective for you.

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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
device. 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 surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99203) and the removal of impacted earwax (69210) rendered by the out of network (OON) provider on January 11, 2021.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99203) and the removal of impacted earwax (69210) rendered by the out of network (OON) provider on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health care provided from March 2, 2021, through March 17, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8-90, for inpatient mental health care.
The enrollee has been asked to pay $1,575 ($225 copayment x 7 days) for the inpatient mental health care provided. 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 the inpatient mental health care provided from March 2, 2021, through March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve the inpatient hospital admission. You say that you will not be able to go directly home after having surgery. You say that medical care is needed after the surgery. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided clearance to undergo this elective procedure. The Plan says that the procedure is approved as an ambulatory procedure and there is no documentation supporting that the enrollee will required greater than 2 midnight stay.
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 pre-approve the inpatient hospital admission.
Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this case. Our physician reviewer found the record indicates that the enrollee has knee osteoarthritis and is scheduled for a knee arthroplasty. The provided records do not indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may spend the initial day in observation until it is clearly expected that a second midnight would be required, at which time the physician may order inpatient admission. 
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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there are no medically complex needs.

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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke treated with thromobolyttic therapy. Medical problems are stable.

There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.