Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have a compromised skin graft where hypoxia or decreased perfusion has compromised its viability. The Plan must follow Medicare rules. Medicare rules say that HBO therapy is covered when the enrollee has a covered indication.  
 
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 therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the records and the treating physician's statement show sufficient evidence to support the use of HBO therapy as part of the enrollee's treatment plan. The records state that the enrollee has a skin flap/graft which is showing signs of microvascular compromise, requiring HBO to help increase circulation to the area and reduce risk of infection while becomes more permanent, which meets criteria. Therefore, the HBO will be considered medically necessary for the enrollee's condition. 
 
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 therapy have been met. Therefore, we decided that the Plan has to preapprove hyperbaric oxygen (HBO) therapy for the enrollee.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services were considered 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services (99284, 93971) provided May 8, 2019.
You asked the Plan to pay for the Emergency Room services. You say that the services were medically necessary. The Plan denied your request. The Plan says insufficient medical records were provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99284 & 93971 are not supported in the medical record. Specifically, documentation does not support 99284, Medical decision making falls under low complexity, resulting in a more appropriate code. Documentation is vague on what type of ultrasound was performed and unable to verify code 93971. Based on this information, we decided that Medicare rules for coverage of the Emergency Room services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room Services (99284, 93971) provided May 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for your routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you don't have anyone to drive you to your surgery. The Plan denied your request. The Plan says your benefit only allows 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Transportation for over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers transportation for up to 50 miles.  Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 pay for the medical services provided to the enrollee by an out-of-network provider on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and an x-ray and coinsurance for an injection provided by a participating on March 12, 2020.
You asked the Plan to waive the copayment and coinsurance for a specialist office visit and an x-ray and coinsurance for an injection. You say that you paid your copayment at the time of service. The Plan denied your request. The Plan says the correct copayment and coinsurance have been applied.
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 $50 copayment for physician/practitioner services/specialist visit, a $60 copayment for outpatient diagnostic tests/x-rays, and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $50 copayment for a specialist office visit and a 20% coinsurance of the allowed amount for injection. The total allowed amount is $24.68. The total amount you are being asked to pay for injections is $4.94 ($24.68 x 20% = $4.94). You have been asked to pay $29.70 which is less than your copayment amount of $60 for an x-ray. The total amount you are being asked to pay is $84.64 ($4.94 + $29.70 + $50 = $84.64). A specialist office visit falls within the physician/practitioner services/specialist visit benefit category, an injection falls within the Medicare Part B prescription drugs benefit category, and an x-ray falls within the outpatient diagnostic tests/x-rays 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 and coinsurance for a specialist office visit, an injection and an x-ray provided by a participating on March 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee is receiving Prolia from a retail pharmacy. The Plan denied your request. The Plan says the drug is not covered under the enrollee's Part B plan.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Benefits for Prolia 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate tab 2.5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a Part D benefit or commercial pharmacy plan administered by this plan.
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 Methotrexate tab 2.5mg for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that 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 enrollee does not have complex medical issues that require acute rehabilitation nursing care or monitoring by an inpatient rehabilitation physician three times per week. While she may well benefit from continuing physical and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to approve an acute inpatient hospital admission. 
 
You asked the Plan to approve acute inpatient hospital care. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 approve acute inpatient hospital care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee presented to the hospital on June 20, 2020 with hyponatremia, severe renoiliac occlusive disease, acute kidney injury, leukocytosis and left lower lobe lung consolidation consistent with pneumonia and acute liver failure. He was treated in the hospital in the intensive care unit with intravenous fluids, intravenous heparin, vascular surgery and gastroenterology consultations, lactulose, thiamine and folic acid, intravenous antibiotics and pantoprazole. The records support that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to approve an acute inpatient hospital admission.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99156, A4550) provided on January 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are bundled services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 99156 is part of an edit pair with procedure code 62284. Procedure code 66284 is a column one code, and procedure code 99156 is a column two code. Procedure code 62284 has been for this date of service, which means that procedure code 99156 is not eligible for payment. 
 
Medicare rules also say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. Code A4550 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for A4550. Therefore, we decided that the Plan does not have to pay for the services (99156, A4550) provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 CFR Section 411.15(h). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the services provided on February 18, 2020, and February 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were
not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan indicates that medical records were viewed in their determination of
medical necessity. However, the plan did not submit records from the contracted provider for the dates of
service in question. A request for additional information was sent to the plan without response. Without
medical records, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for
the services provided on February 18, 2020, and February 19, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that the minimally invasive procedure is the most appropriate for the enrollee. The Plan denied your request. The Plan says medical literature has not demonstrated the clinical value and long-term effectiveness of the procedure.
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 requested services. Our physician reviewer found that the requested spacer is experimental. More research is needed to show its safety and efficacy. Therefore, the requested device is not medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous spacer device.
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 admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the care in an alternate setting. 
 
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator and supplies purchased on December 12, 2019. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you were directed to a supplier for the purchase of the portable oxygen concentrator and supplies. That company did not sell oxygen equipment so you purchased the equipment from a different supplier. The Plan denied your request. The Plan says Medicare rules say that only rented oxygen equipment is eligible for coverage. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Purchased oxygen equipment is not covered by Medicare.   
 
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on December 12, 2019.