Persius/hicric huggingface dataset:
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 IRF criteria. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Ongoing
medication management, wound care, and daily therapy can be provided at a skilled nursing facility. In this
case a less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would
be able to fully participate in and/or benefit from 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis and office visit provided on September 11, 2019.
You asked the Plan to waive the copayments for the arthrocentesis and office visit. You say that you went for a cortisone shot but it was billed as outpatient surgery. You say that you want to appeal your copayments. The Plan denied your request. The Plan says the copayments 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 $290 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility and a $35 copayment per visit for Medicare-covered specialty care services. You have been asked to pay a total of $299.69 for the arthrocentesis and office visit.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
September 11, 2019
Arthrocentesis
$264.69
$290
$264.69
September 11, 2019
Office Visit
$52.67
$35
$35
TOTAL:
$299.69
The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities ambulatory surgical centers" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The arthrocentesis is considered a surgical procedure. 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 copayments for the arthrocentesis and office visit provided on September 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS HF System (C2624 and 33289).You asked the Plan to pre-approvea CardioMEMS HF System (C2624 and 33289). You say that the requested CardioMEMS HF System is medically necessary.The Plan denied your request. The Plan says the requested CardioMEMS HF System is 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 a CardioMEMS HF System (C2624 and 33289). Our reviewer says that the requested CardioMEMS HF System is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, hyperlipidemia, diabetes, obstructive sleep apnea, hypothyroidism and congestive failure with preserved ejection fraction requiring hospitalization. A request was made for placement of a CardioMEMSdevice. In this circumstance therapy change based ondata obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS HF System (C2624 and 33289) have not been met.Therefore, we decided that the Plan does not have to pre-approvea CardioMEMS HF System (C2624 and 33289).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 14, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you are not sure how you ended up on the floor. You say that you shouldn't be responsible for the copayment. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" 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 ED visit provided on September 14, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 8, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you shouldn't be responsible for the copayment. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" 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 ED visit provided on August 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance services (A0429) and ground
ambulance (A0425) provided August 18, 2019.
You asked the Plan to pay for the ambulance services. You say that you acknowledge this service was not
medically necessary and do not expect reimbursement, this request is solely to allocate the charges as patient
responsibility. The Plan denied your request. The Plan says the submitted documentation does not support
medically necessity.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance services. Our reviewer says
that the ambulance transport on was not medically reasonable and necessary for this enrollee. Our physician
reviewer found the documentation did not support that the enrollee needed the expertise, services and
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.
The enrollee had stable vital signs and no need for BLS or ALS monitoring.
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 ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the BLS emergency ambulance services (A0429) and ground ambulance (A0425)
provided August 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided at the in-network benefit level by out of network provider.

You asked the Plan to pre-approve in-network coverage for endocrinology services. You say that you receive treatment on a daily basis, this provider is the best in the world, and you are on a limited income. The Plan denied your request. The Plan says the denial of authorization at the in-network benefit level is correct, because this provider is out-of-network with the Plan and you could be treated within the Plan network.

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 at the in-network benefit level from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. This Plan also has a Point-of-Service (POS) benefit that covers out-of-network physician specialist services at 20% coinsurance if the provider accepts Medicare assignment or 35% coinsurance if the provider does not accept Medicare assignment.

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 at the in-network benefit level. You may choose to receive services from this provider using the Plan's Point-of-Service (POS) benefit, and would be responsible for the POS-level cost-sharing amounts. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided at the in-network benefit level by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
March 27, 2019 to March 29, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, home health
services are required to have the appropriate Q codes to process and pay the final claims. This information is
missing from the claim. Therefore, we decided that the Plan does not have to pay for the home health services
provided to the enrollee from March 27, 2019 to March 29, 2019.
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 are ready to discharge from the hospital but are too weak to return home. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit from and participate in additional therapies of physical therapy and occupational therapy, but you do not require this on an intensive rehabilitation 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Peroral Endoscopic Myotomy (POEM).
You asked the Plan to pre-approve the requested service. You say that you have issues digesting food. The Plan denied your request. The Plan says that the requested procedure is considered experimental.
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 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 service. Our physician reviewer found that you have a diagnosis of Achalasia, type II. You have had dysphagia for 15 years. It is documented that you have dysphagia, regurgitation, and chest pain with every meal. You have lost approximately 15 pounds. The documentation in the case file supports that a Peroral Endoscopic Myotomy procedure is medically reasonable and necessary. You have severe symptoms from your condition, and is at risk for serious complications. You have been thoroughly evaluated by appropriate specialists. The medical literature supports that POEM is a reasonable and effective treatment option for patients with Achalasia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pre-approve a Peroral Endoscopic Myotomy (POEM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the TCM therapy visits provided from July 30, 2019 to September 19, 2019.
You asked the Plan to waive the copayments for the TCM therapy visits. You say that you are appealing the $20 charge for each visit. You say it was only one "treatment" and not 37 separate "treatments." 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for each in-network Medicare-covered visit. The enrollee has been asked to pay a $20 copayment for each of the TCM therapy visits. ($20 x 19 visits = $380). The TCM therapy visits falls within the "Outpatient mental health care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the TCM therapy visits provided from July 30, 2019 to September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye injection provided on August 30, 2018.You asked the Plan to waive the copayment forthe eye injection. You say that you did not have a minor surgery. You say that you were informed you only be billed for an office visit.The Plandenied 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 Planclearly says that you must pay a $275 copayment for each Medicare-covered outpatient surgery in an in-network ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $275 copayment for the eye injection. The eye injectionfalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The eye injection is considered a surgical procedure. 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 forthe eye injection provided on August 30, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the folding wheeled walker purchased on
September 24, 2019 from an out of network provider.
You asked the Plan to reimburse you for the walker. You say that your doctor recommended you use a walker
in the house as well as outdoors. The Plan denied your request. The Plan says you did not request 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 reimburse you 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 reimburse you for these
items/services. Therefore, we decided that the Plan does not have to reimburse you for the folding wheeled
walker purchased on September 24, 2019 from an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on January 16, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory testing provided on January 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued referral to an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says medically necessary care is available in-network.
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 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. 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 continued referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection, expandable controller, and an expandable controller harness for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to control the three approved power options through the joystick (drive interface).
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 accessories. Our reviewer says that
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength is sufficient to control the power options with their separate switches already included with the approval of these power options. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection, expandable controller, and an expandable controller harness for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole Magnesium Capsules 40 mg.
You asked the Plan to pre-approve Esomeprazole Magnesium Capsules. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Esomeprazole Magnesium Capsules are not covered under the enrollee's Medicare Part B 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 Esomeprazole Magnesium Capsules 40 mg.
Benefits for Esomeprazole Magnesium Capsules may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.