Persius/hicric huggingface dataset:
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) for the enrollee.
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 care can be provided in the current inpatient hospital.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including oxygen supplementation and ventilator support, intravenous antibiotics, surveillance laboratory studies, hemodialysis, 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-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has chronic weakness, and does not require an intensive team to oversee rehab care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's current medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries provided on October 3, 2019 to October 17, 2019.
You asked the Plan to waive the copayments for the cataract surgeries. You say that no one told you there would be a copayment for cataract 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each outpatient surgery and/or service at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayments for the cataract surgeries provided on October 3, 2019 to October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 25, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this should have been billed as an annual visit. You say that you should not have to pay. 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 $20 copayment for each primary care doctor visit for Medicare-covered benefits.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that this was a new patient office visit. 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 office visit provided on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seat lift mechanism (E1399).
You asked the Plan to pre-approve the seat lift mechanism. You say that you are requesting reconsideration because you have bad vertigo and cannot get up on your own. The Plan denied your request. The Plan says the request for a seat lift mechanism is not medically necessary.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the seat lift mechanism. Our reviewer says that the requested for the seat mechanism is not medically necessary. Our physician reviewer found the documentation does not reveal objective evidence of severe hip arthritis or a neuromuscular disease. The documentation does not reveal that a seat lift is included in the physician's course of treatment or that a seat lift will improve or retard/arrest the patient's condition. The records do not reveal that the enrollee is incapable of standing from a chair in the home. The records do reveal that the enrollee can ambulate as he is independent with bed to chair transfers and dependent with ambulation. The records reveal she is not bed bound and uses no assistive device but is a fall risk. The enrollee denies falls but has problems with instability and impaired functional mobility. There is no gait evaluation. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve seat lift mechanism (E1399).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for ultrasonic guidance for needle placement (76942) provided on July 9, 2019.
You asked the Plan to pay for ultrasonic guidance for needle placement. You say that this was incorrectly denied. The Plan denied your request. The Plan says that this service must be billed with Modifier 26.
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, the Plan did not submit documentation showing whether the technical and professional components of this service were provided by the same physician/supplier entity in the same payment locality. The case file did not contain any information on how the technical component was billed. Without this information, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for ultrasonic guidance for needle placement (76942) provided on July 9, 2019.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for therapeutic exercises (97110) provided on May 9, 2019.
You asked the Plan to pay for therapeutic exercises. You say that this should be paid. The Plan denied your request. The Plan says that this service was billed incorrectly.
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, the plan has not submitted any records or other information about their denial of this service. Though the Plan states this service was billed incorrectly, the file does not contain a claim showing how the service was billed or medical records to show what service was performed. Without this information, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay for therapeutic exercises (97110) provided on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Venofer infusion at the hospital for the enrollee.
You asked the Plan to pre-approve the infusion. You say that this is medically necessary. The Plan denied your request. The Plan says there is a network provider available for this infusion.
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 Venofer infusion at the hospital for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair with elevated leg rests.
You asked the Plan to pre-approve the lightweight wheelchair with leg rests. You say that the enrollee is not able to maintain safely walking with a walker and needs the requested wheelchair. The Plan denied your request. The Plan says the enrollee is noted to have the ability to use a walker. Therefore, the wheelchair is denied.
The Plan follows Medicare rules. Medicare rules say that lightweight wheelchairs are covered when an enrollee cannot self-propel in a standard wheelchair. Elevated leg rests are covered when reasonable and necessary based on the above listed conditions. 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 lightweight wheelchair with leg rests. Our reviewer says that the requested equipment is not shown to be medically reasonable and necessary at this time. Our physician reviewer found the physician appeal documentation indicates the patient can self-propel in a lightweight wheelchair however the therapy documentation reveals the patient can propel a wheelchair but is not specific whether it is lightweight or standard. Therefore, it is not clear that the patient is unable to self-propel in a standard wheelchair in the home. The documentation does not reveal lower extremity edema, a need for a reclining back on chair, or cast/brace that prevents ninety degree flexion at knee. 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 lightweight wheelchair with leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair with elevated leg rests.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for a back brace. We decided that the Plan does not have to waive the
cost-sharing for office visits and orthotics.
You asked the Plan to pay for a back brace. You say that these items and services should be covered. The Plan
says that these claims processed correctly.
We decided that the Plan has to pay for a back brace.
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent
efforts to gather and forward information to the Independent Review Entity (IRE).
We looked at the file and Medicare rules. The Plan did not submit any medical records or information about
why this item was denied. Without this information, their denial cannot be substantiated. Therefore, we decided
that the Plan has to pay for a back brace.
We also decided that the Plan does not have to waive the cost-sharing for office visits and orthotics.
The Plan follows Medicare rules. Medicare rules say that a health 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 states that that you pay a $20 copayment for in-network primary care visits, a $25 copayment for
in-network specialist visits, and 50% coinsurance for each out of network specialist visit. It also states that
there is a $490 deductible.
The file shows that you have been asked to pay $20 for a primary care visit, $25 for an in-network specialist,
and $87.65 (50% of the allowed amount of $175.30) for an out-of-network specialist. It also shows that you
have been asked to pay $370.66 towards your $490 deductible, which had not yet been met, for orthotics.
Therefore, we decided that the Plan does not have to waive the cost-sharing for office visits and orthotics.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one-way routine transportation trips that exceed 50 miles each way.
You asked the Plan to pre-approve the one-way routine transportation trips exceeding 50 miles each way. You say that your provider is requesting to see you before they will prescribe you your mediation. You say that you will be out of this medication on February 7, 2020. The Plan denied your request. The Plan says the request exceeds the limitations set in the subscriber agreement for coverage of routine transportation trips.
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. The Plan covers up to 36 one-way routine transportation trips when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The records show that the location you are requesting transportation to is more than 50 miles from your home address. Based on this information, we decided that the Plan's rules for coverage of routine transportation trips have not been met. Therefore, we decided that he Plan does not have to pre-approve one-way routine transportation trips that exceed 50 miles each way.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided by on August 22, 2019 and August 29, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that these visits were follow-ups for a surgery on August 13, 2019. You say you have had follow-ups in the past and have never had to pay an additional copayment. 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 $50 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $50 copayment for the each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to 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 specialist office visits provided on August 22, 2019 and August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the annual wellness visit provided on August 23, 2019.
You asked the Plan to waive the coinsurance for the annual wellness visit. You say that you did not receive the services and you should not be responsible for the cost sharing amount. 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 50% of the Medicare-allowed amount for the out-of-network Medicare-covered annual wellness visit. You have been asked to pay $104.38 which is 50% of the allowed amount for the annual wellness visit. The allowed amount is $208.76. ($208.76 x 50% = $104.38). The annual wellness visit falls within the "Annual wellness visit" benefit category. The record shows you received the services.
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 coinsurance for the annual wellness visit provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit 10,000 unit/ml vial.
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 information about the case doesn't include the diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the received documentation does not include any medical records, provider notes, or laboratory results. Without this documentation, medical necessity cannot be determined. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit 10,000 unit/ml vial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these same injections failed to provide the required benefit in treating the pain.
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 services. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the LCD requires 80% pain relief in order for the diagnostic block to be considered positive.
This was not achieved and therefore, the request is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection for the enrollee.