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

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care, and does not require transfer to an LTACH.
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 is currently undergoing treatment at an acute care hospital (ACH). Shortly after admission, the enrollee suffered a cardiac arrest, for which she was intubated/ventilated. The enrollee subsequently developed seizures and received a tracheotomy. The enrollee has not been able to tolerate ventilator weaning in part due to pulmonary bleeding, which does not yet appear to be under control. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid. The Plan denied your request. The Plan says the stockings do not meet the statutory definition of a surgical dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient services for the enrollee.
You asked the Plan to pre-approve inpatient services. 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 inpatient services. Our reviewer says that the documentation does not support that the requested inpatient services are medically reasonable or necessary. Our physician reviewer found the enrollee was brought to the emergency department for concern for adult failure to thrive after being found in her home with only frozen dinners to eat and no way to heat the meals. The enrollee had frequent recent admissions to rehabilitation or skilled nursing facilities. The enrollee had been discharged from skilled nursing at the enrollee's request two days prior to this admission. There were no acute symptoms or complaints. Examination revealed no acute abnormalities. The admitting physician documented that there were no no medical problems to support inpatient admission. The enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of inpatient services. The medical record documents a concern that the enrollee cannot care for herself in the home environment but there are no acute medical problems for which inpatient hospital admission is 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient services.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve four home health physical therapy visits.
You asked the Plan to pre-approve four home health physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 four home health physical therapy visits. Our reviewer says that the services are medically necessary. Our physician reviewer found the records do show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for you. You have made substantive progress with physical therapy thus far and there is reasonable expectation documented by the treating clinician that ongoing services with provide additional progress to independence. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of four home health physical therapy visits have been met. Therefore, we decided that the Plan has to pre-approve four home health physical therapy visits.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility services provided to the enrollee from June 10, 2019 to June 14, 2019.You asked the Plan to pay forskilled nursing facility services provided to the enrollee from June 10, 2019 to June 14, 2019. You say that this claim should be paid.The Plan denied your request. The Plan says that An incorrect Core Based Statistical Area (CBSA) number for value code 61 was used. Chapter 10 of the Medicare Claims Processing Manual, which is for Home Health Agency Billing, speaks to the requirement of a CBSA when value code 61 is 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 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. There were 9pages in the file submitted. Other than the denial letter there were no medical records or specific explanation of the case itself. The Plan submitted an incomplete case file from which we are unable to substantiate the Plans denial. Therefore, we decided that the Plan has to pay forskilled nursing facility services provided to the enrollee from June 10, 2019 to June 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cystourethroscopy provided on October 1, 2019.
You asked the Plan to waive the cost share for the cystourethroscopy. You say that you should be reimbursed for your surgery. 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. Your contract with the Plan says that there is a $245 deductible that applies towards in-network outpatient surgery and 10% of the cost for each Medicare-covered ambulatory surgical center visit. The cystourethroscopy you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $245 deductible that applies towards outpatient surgery and 10% of the cost for each Medicare-covered ambulatory surgical center visit.
This cost sharing is a contractual obligation that had not been met at the time the cystourethroscopy was received on October 1, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the cystourethroscopy provided by on October 1, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve admission to an IRF. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet criteria.
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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 you are currently undergoing treatment at an ACH for pneumonia and influenza. You were intubated/ventilated and subsequently received a tracheotomy. You have since been weaned from the ventilator and is tolerating a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care from January 1, 2020 and forward.
You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the requested continuation of SNF care does not meet criteria.
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 continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF on 11/26/19 after a urinary tract infection. The enrollee had a decline in function. At baseline, the enrollee could toilet and walk household distances with a rolling walker and supervision. On 12/16/19 the enrollee was ambulating 90 feet x 2 with minimal assist and wheelchair follow through. On 1/3/20 the enrollee was minimal assist for transfers. This enrollee does not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and
effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 continuation of skilled nursing facility (SNF) care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care from January 1, 2020 and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on May 23, 2019 by the out of network provider. You asked the Plan to pay forphysician services. You say that your provider treated the member while hospitalized. You say that your provider cannot deny and medical service that is essential to the member's health treatment.The Plan denied your request. The Plan says the member has no out-of-network benefits.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided on May 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the optometry visit provided on May 30, 2019.
You asked the Plan to waive the copayment for the optometry visit. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). According to your claims history this visit on May 30, 2019 was not your first optometry visit of the year. The records indicate that you had an initial optometry visit with this provider on February 12, 2019 and you did not have a copayment due for that date of service. Per your health plan benefit, you are responsible for a $50 copayment for subsequent optometry visits. 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 optometry visit provided on May 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).You asked the Plan to pre-approve the Gel-One. You say that the Gel-One is medically necessary. The Plan denied your request. The Plan says the member does not meet the step-therapy exception criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Gel-One. Our reviewer says that the documentation does not show that the enrollee has tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the records do not indicate that the preferred drugs would be unsafe or ineffective.
We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on November 29, 2018.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 provider type is not covered.The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS.We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on November 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by an out-of-network provider.
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 services were rendered by a non-contracted 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 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 6, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Dronabinol.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional PT sessions.
You asked the Plan to pre-approve the additional PT sessions. You say that the enrollee continues to have significant safety concerns, falls and high fall risk status. You also say that the enrollee has shown significant progress to date and would benefit from further therapy. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found for balance impairment, PT is generally accepted as specific and effective therapy. Our reviewer found that goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. Our physician reviewer found that there is no indication residual deficits could not be addressed via a HEP. Our reviewer also found that HEP compliance is noted as high. 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 additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional PT sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a scooter. You say that you cannot walk across your floor because of your legs. The Plan denied your request. The Plan says you do not meet the criteria for a power mobility device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. Your physical therapy assessment shows you are able to ambulate in your home, you are modified independent with MRADLs, and you use a rollator. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.