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

We decided that the Plan does not have to pay for dialysis medication (J0887) for the enrollee.

You asked the Plan to pay for this drug as requested. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug cannot be approved in the format requested. The Plan states this medication cannot be separately billed when provided at a dialysis facility for the diagnosis of End Stage Renal Disease. The decision is based solely on whether the coverage and payment would be responsible under Medicare Part B or Part D benefit. The requested drug should be billed to Medicare Part B dialysis bundled by the facility.; therefore, the denied authorization is upheld.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this request created an administrative error because it is not being requested appropriately. Medicare rules for coverage of this drug as requested have not been met. Therefore, we decided that the Plan does not have to pay for dialysis medication (J0887) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hair transplant.

You asked the Plan to pre-approve hair transplant. You say that a hair transplant is medically necessary. The Plan denied your request. The Plan says Medicare does not cover hair transplant.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.

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 hair transplant. Our reviewer says that you have a history of Hodgkin's lymphoma and has drug induced alopecia secondary to chemotherapy. You are going out of the country and would like a hair transplant. However, as hair transplant does not meet medical necessity, it would be considered cosmetic in nature and is not covered by Medicare. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hair transplant have not been met. Therefore, we decided that the Plan does not have to pre-approve hair transplant.
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different 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. Our
physician reviewer found based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an
IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue debridement services provided by an out of network (OON) provider.

You asked the Plan to pay for the services provided. 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 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 pay for the tissue debridement services provided 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 enrollee is unable to perform daily functions. The
Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for congestive heart failure and cellulitis. The medical problems are stable and she has no complex
nursing or rehabilitation needs. She 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. There is not a reasonable expectation that the 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 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 gene panel testing.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the testing is not a Medicare benefit for the diagnoses listed on the claim.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

In this case, there were insufficient medical records to show the services were provided to determine a specific diagnosis or treatment strategy. There are no records to show the testing correlates with given interventions. The test at issue was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the gene panel testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heparin and Venofer to be provided with hemodialysis services.

You asked the Plan to pre-approve the heparin and Venofer. You say that these services are medically necessary. The Plan denied your request. The Plan says the drugs requested are for use with hemodialysis and are included in the payment made to the facility. The facility must directly, or under arrangements, provide and bill for these items.

The Plan must follow Medicare rules. Medicare rules say that separate payment is not made for drugs provided to dialysis patients when the drugs are directly used for the treatments. Therefore, we decided that the Plan does not have to pre-approve heparin and Venofer to be provided with hemodialysis services.
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 you need IRF care. The Plan denied your request.
The Plan says IRF care 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. In addition, 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. Finally, there is not a reasonable expectation that this patient
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 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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you trust this facility. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital with respiratory failure and congestive heart failure. Your medical problems are now stable and you have 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ProAir HFA inhaler.
You asked the Plan to pre-approve ProAir HFA. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not 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 the ProAir HFA inhaler.
Benefits for ProAir HFA 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network laboratory.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network laboratory.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a life vest.
You asked the Plan to pay for a life vest. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. Review of the file shows that you enrolled in hospice on March 4, 2021. You are under the Medicare hospice benefit. Therefore, we decided that the Plan does not have to pay for a life vest.
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 care is medically necessary. The Plan denied your request. The Plan says the current facility is able to meet all needs.

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 enrollee was admitted to the acute care hospital with respiratory failure, weakness and a myocardial infarction. The enrollee has chronic lower extremity wounds, with cellulitis of the right leg. The enrollee was in no acute distress.

Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 14, 2020.
You asked the Plan to pay for the ambulance services. You say that you cannot afford this bill. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 14, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 14, 2020.
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 is medically necessary. The Plan denied
your request. The Plan says rules for 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 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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the
patient 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. Finally, there is not a reasonable expectation that
this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray.

You asked the Plan to waive the copayment for the x-ray. You say that you should not be responsible for the copayment because the x-ray was done to confirm that the tuberculosis test was a false positive. The Plan denied your request. The Plan says you have been asked to pay 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 $15 copayment when x-rays are performed in an independent diagnostic testing facility.

You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the right ankle-foot orthosis (AFO) coded as L1971 and infrared wand provided on September 30, 2020.
You asked the Plan to pay for the AFO and infrared wand. You say that these items should be covered. The Plan denied your request. The Plan says the criteria for coverage of these items have not been met.
The Plan follows Medicare rules. Medicare rules say that AFOs such as those described by L1971 may be covered when the criteria noted in the Medicare rules section 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 pay for the AFO and infrared wand. Our reviewer says that the documentation does not support that the criteria for coverage of the AFO provided have been met. Our physician reviewer found while the documentation reveals the patient is ambulatory, there is no objective evidence on a physical examination of weakness or deformity of the foot and ankle with a need to stabilize the ankle/foot for medical reasons and that this orthosis will cause the patient to have functional benefit.
The rules also say that infrared therapy devices are noncovered by Medicare. 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 AFO and infrared wand have not been met. Therefore, we decided that the Plan does not have to pay for the right ankle-foot orthosis (AFO) coded as L1971 and infrared wand provided on September 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 5, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the hospital initiated the ambulance call to be transported to another hospital. You say that you should not bear the burden of the costs. 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 $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 the ambulance transport provided on July 5, 2020.