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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 1, 2020 with multiple compression fractures. The physical therapy evaluation on February 3, 2020 states she needed minimal assist with standing up to sitting down and walking 15 feet. The records do not show any complex medical, nursing, or rehabilitation needs that require the intensity of services provided at an IRF. She may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 12, 2019 to August
29, 2019 by an out-of-network provider.
You asked the Plan to pay for these services. You say that you were not told that the provider was out-of network.
The Plan denied your request. The Plan says the services were rendered by an out-of-network
provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 12, 2019 to
August 29, 2019 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF 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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. The enrollee was treated for pain with effect. The enrollee's lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy (PT) in the acute hospital. The enrollee was at a stand by assist level to contact guard assist level with functional mobility including gait to 120 feet with a rolling walker. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 26, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records for these tests and laboratory results have not been submitted to justify coverage of this claim.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab tests billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from April 23, 2019
through May 18, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you were not aware all of the days were
not covered. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019
EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on April 23, 20197 and were discharged on May 18, 2019.
There were no copay charges for the first 20 days (April 23, 2019 through May 12, 2019). You are asked to pay
a $160 copayment per day for SNF services provided on May 13, 2019, your 21st day of SNF care through
May 17, 2019. You were discharged on May 18, 2019 and there was no copayment charge for the day of
discharge. Per your contract there is a $160 copayment required for days 21-100. 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 SNF care provided from April 23, 2019 through May 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cologuard testing rendered on April 17,
2019.
You asked the Plan to pay for these services. You say that the plan is required to process the claim. The Plan
denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered when specific
criteria are met.
We looked at the file and Medicare rules. The file contains no documentation to support that the enrollee met
the criteria for coverage of the Cologuard testing. Therefore, we decided that the Plan does not have to pay for
the Cologuard testing rendered on April 17, 2019.
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 the enrollee has failed multiple weaning
trials. 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 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 services are not medically necessary. Our physician reviewer found the enrollee is currently
undergoing treatment at an acute care hospital (ACH), having been admitted with shortness of breath. Initially
treated for CHF and pneumonia, the enrollee was determined to have lung cancer. The enrollee required
intubation/ventilation and subsequently received a tracheotomy. The enrollee remains on a ventilator. The enrollee's
overall prognosis appears to be poor. 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.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup.
You asked the Plan to pre-approve the backup. You say that you need this in case the electricity goes off. The Plan denied your request. The Plan says this is not a covered item.
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 backup. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no medical records were provided for review. Therefore, there is no evidence to support that the requested service is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 backup have not been met. Therefore, we decided that the Plan does not have to pre-approve a battery backup.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. Based on the documentation provided, the enrollee has not tried and failed the Plan's required drugs, Orthovisc and Monovisc first. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
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 IRF setting would be best. The Plan denied your request. The Plan says there is no acute medical condition and no need for three hours of daily intensive therapy.
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 admitted on 1/26 for exacerbation of COPD. falls. weakness. He was recently hospitalized with COPD, SOB, and pneumonia. He is currently ambulating 175 feet with a rolling walker with contact guard assist, is modified independent with bed mobility and transfers, and is toileting with supervision. Based on available records, the patient does not meet criteria for coverage of IRF. The patient is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the facial area.
You asked the Plan to pre-approve these services. You say that you are having issues walking. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of narrowing of the neck spine (cervical spinal stenosis) with progressive neck and back pain. You have weakness and difficulty walking. The records do not discuss any clinical findings or rationale for the requested CT scan of the face. The CT scan is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the facial area.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for lateral retinacular release (27425) provided on May 18, 2019.
You asked the Plan to pay for the lateral retinacular release. You say that the services rendered were medically
necessary. The Plan denied your request. The Plan says CPT code 27425 is not a valid code for an assistant at
surgery because it assigned an Assistant Surgery Indicator of 1.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code
27425. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based
upon this information, we find that Medicare coverage criteria for the lateral retinacular release have not been
met. Therefore, we decided that the Plan does not have to pay for lateral retinacular release (27425) provided
on May 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis
vaccine (Tdap) shot you received on August 23, 2019.
You asked the Plan to pay for the services provided. You say that you had to have a Tdap shot to visit your
granddaughter. The Plan denied your request. The Plan says a tetanus vaccination is not covered as a
preventive service.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services
provided. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the services
provided. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and
acellular pertussis vaccine (Tdap) shot you received on August 23, 2019.
Benefits for the services provided 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon during arthroscopy services provided
on September 5, 2019.
You asked the Plan to pay for the assistant surgeon 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 not a covered benefit.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon during
arthroscopy services provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lymphedema compression sleeve.
You asked the Plan to pre-approve a lymphedema compression sleeve. You say that because of a surgery you need a lymphedema compression sleeve. The Plan denied your request. The Plan says a lymphedema sleeve is covered as durable medical equipment only if it is part of the pneumatic compression device used to treat lymphedema not as a separate durable medical equipment item.
The Plan must follow Medicare rules. The rules say that compression sleeves are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a lymphedema compression sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 standard power wheelchair and accessories.You asked the Plan to pre-approvea Group 3 standard power wheelchair and accessories. You say that you need a power wheelchair for your mobility issues with MRADLs. The Plan denied your request. The Plan says there is nodocumentation of a home assessmentor a face-to-face evaluation with your physician.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.The file does not contain a physician face-to-face, orshowthat you can safely operate the PMD being requestedin your home.The home assessment was done in a skilled nursing facility.This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3 standard power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 18, 2019 by out of network provider.
You asked the Plan to pay for laboratory testing. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring practitioner is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 18, 2019 by out of network provider.