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

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on September 10, 2019.You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you never went to any special room to receive the injection. 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center of hospital outpatient facility. You have been asked to pay a $250 copayment for the outpatient clinic visit. The outpatient clinic visit falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were charged by the hospital for the outpatient clinic visit for the cortisone shot.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 outpatient clinic visit provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
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-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACHis not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for sacral osteomyelitis. The enrollee is receiving wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate forthe one first intraoral periapical x-ray (D0220), prefabricated post and core (D2954), pontic (D6245), and core buildup (D2950), provided on October 7, 2019.You asked the Plan to pay the in-network rate forthe one first intraoral periapical x-ray (D0220), prefabricated post and core (D2954), pontic (D6245), and core buildup (D2950). You say that you were told by several people, including a Plan representative and the providers office, that this provider was an in-network provider.The Plan denied your request. The Plan says prefabricated post and core in addition to crown, pontic, and core buildup are not covered services. The Plan also says that the benefits for the intraoralx-rays have been satisfied and the frequency limitation had been exceeded. 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, prefabricated post and core in addition to crown, pontic, and core buildup are not among those covered under this benefit. The contract also says that intraoral x-rays are limited to one set per calendar year. The record shows that you received a first intraoral periapical x-rays and an additional intraoral periapical x-ray on September 30, 2019 and your intraoral x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay the in-network rate forthe one first intraoral periapical x-ray (D0220), prefabricated post and core (D2954), pontic (D6245), and core buildup (D2950), provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says tier exceptions are only possible for certain Part D drugs.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the requested items. You say that the device facilitates adjustments in pump settings, promoting optimal glucose control. The Plan denied your request. The Plan says the requested device is not a therapeutic continuous glucose monitor, and not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file, and Medicare rules. Based on the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Evenity for the enrollee.You asked the Plan to pre-approvea tier exception. You say that the enrollee is stable on this drug.The Plan denied your request. The Plan says that Medicare rules say Part B drugs are not eligible to be moved to a lower cost level and that tier exceptions apply to Part D covered medications.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approvea tier exception for Evenity for the enrollee
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 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 enrollee required moderate assistance for sit to stand with a rolling walker. The enrollee required moderate assistance to walk with a rolling walker. 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. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH servicesare 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 wascorrect in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include surveillance laboratory studies, neurologic monitoring, transfusions, iron supplementation, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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-approvelong term acute care hospital (LTACH) 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 the enrollee meets the IRF admission criteria under CMS guidelines.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy at home to transition for mobility at home, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.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 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 and the enrollee meets Medicare criteria for placement. You say that the enrollee has been denied by all lower levels of care and has numerous complex needs that require an acute care setting.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services the enrollee needs can be provided in another 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a motor vehicle collision resulting in traumatic brain injuries and a cervical spinal cord injury. The enrollee is noted to be a paraplegic. The enrollee was intubated/ventilated and eventually received a tracheotomy. Given the level of his spinal injuries, it is questionable whether the enrollee can be fully liberated from a ventilator or that he can be safely decannulated. He would seem to be at high risk for respiratory events (aspiration, pneumonia, mucous plugging, atelectasis) requiring repeat/recurrent respiratory assistance going forward. There is no advantage in transferring the enrollee to the LTACH. The enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 3, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 3,2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the records provided support the need for a
continuation of SNF care. The Plan denied your request. The Plan says the criteria for coverage have not been
met. The Plan says that the enrollee's needs can be met at a lower level of 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 care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does require the oversight of
her medical conditions and medication management. The enrollee is at risk for secondary complications of
immobility such as pressure ulcers and contractures, as well as recurrent fall related injuries. The enrollee also
requires physical therapy for mobility and occupational therapy for remaining activities of daily living and
adaptive equipment. However, these skilled needs do not need to be provided on a daily basis. Although the
enrollee now requires moderate rather than minimal assistance with activities of daily living, she is receiving
care that can be provided by her non-skilled caregivers with periodic skilled oversight and modification of the
care plan if needed. The enrollee's condition would not be expected to deteriorate with services provided on a
less than daily basis. The enrollee's care can be continued at an alternate level. Consideration could be given to
an evaluation in the assisted living facility to see whether she is able to function better in her own familiar
environment. Alternatively, the enrollee's care can be provided at a custodial level with intermittent skilled
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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a  glucose monitor and supplies.
You asked the Plan to pre-approve a Contour Next One glucose monitor and supplies. You say that your doctor suggests you use a much more accurate device. The Plan denied your request. The Plan says you are pre-diabetic which is not a covered diagnosis for diabetic supplies under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Contour Next One glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a glucose monitor and supplies.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has topre-approve transthoracic echocardiogram.You asked the Plan to pre-approve the transthoracic echocardiogram. You say that you would like reconsideration as this service is medically necessary. The Plan denied your request. The Plan says thatthe documentation does not include the results of the last test or why a repeat test is necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the transthoracic echocardiogram. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the record, you have moderate-to-severe aortic regurgitation documented on an echocardiogram about 1 year ago and recent symptoms and findings that may be related to progressive aortic regurgitation. In this circumstance a repeat echocardiogram about 1 year after the prior exam is reasonable and appropriate.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thetransthoracic echocardiogram have been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiogram.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging (92134) provided on June 10, 2019.
You asked the Plan to pay for scanning computerized ophthalmic diagnostic imaging. You say that this code is supported by the record. The Plan denied your request. The Plan says the records that support this code are for a different date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 92134 is scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina. We find that CPT code 92134 is not supported in the medical record. Specifically, the imaging records included in the case file were for a different date of service than the one billed. Based on this information, we decided that Medicare rules for coverage of scanning computerized ophthalmic diagnostic imaging have not been met. Therefore, we decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging (92134) provided on June 10, 2019.