Persius/hicric huggingface dataset:
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 you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that transfer to a LTACH is not medically necessary at this time. The enrollee is receiving appropriate care in the current acute care facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an acute care hospital (ACH) for pneumonia. The enrollee has received antibiotics.The enrollee arrived with a tracheotomy and feeding tube following a prior hospitalization. The enrollee continues to receive nighttime ventilator support, commiserate with her diagnoses of obstructive sleep apnea(OSA)and obesity hypoventilation syndrome(OHS). It is unclear if decannulation is expected or warranted. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-termcare needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 8, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid 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/lab requisition stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 10, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records for the billed date of service.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/lab requisition stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 6, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.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 tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the lab services provided on June 6, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve ultraviolet light therapy (96900).You asked the Plan to pre-approve ultraviolet light therapy. You say that this is medically necessary.The Plan denied your request. The Plan says that this is cosmetic.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 ultraviolet light therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record shows that the enrollee has vitiligo. Ultraviolet  phototherapy is the standard of care for vitiligo, therefore, the requested treatment is considered 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 ultraviolet light therapy have been met.Therefore, we decided that the Plan has to pre-approve ultraviolet light therapy (96900).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: Unfavorable

We decided that the Plan does not have to pre-approvethe chiropractic services to be provided by an OON provider.You asked the Plan to pre-approvethe chiropractic services. You say that you have a special condition with your neck and have always gone to a chiropractor who is OON. You also say that you called in and submitted an authorization request but it was denied.The Plan denied your request. The Plan says there is no medical necessity identified to use this out-of-network provider. The Plan also says there are multiple providers 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 care that cannot be provided by network providers.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-approvethe chiropractic services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your doctor sent all of the required information for the requested orthotics to the Plan. You say that you have had the requested orthotics covered in the past by other insurance companies. You requested an appeal to try to get the Plan to cover the orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve more than 21 additional OT visits.
You asked the Plan to pre-approve 36 additional OT visits. You say that if you stop the therapy you might regress. The Plan partially denied your request. The Plan says more than 21 additional OT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 partially denying the request to pre-approve 36 additional OT visits. Our reviewer says that the requested additional therapy beyond what was approved by the health plan is not medically necessary. Our physician reviewer found the therapy would not be generally accepted as specific and effective therapy for your condition as you have had extensive therapy for this condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist for more than 21 additional visits. The 21 additional visits approved by the plan is sufficient to develop and implement the customized home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of more than 21 additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve more than 21 additional OT visits.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care services under the Medicare portion of the enrollee's plan coverage.You asked the Plan to pre-approve the adult day care services. The Plan denied your request. The Plan says custodial care is not covered. Medical day care is covered by the Medicaid portion of the enrollee's plan.We looked at the file and the Plan's rules. The file shows that the Plan says custodial care is not a covered benefit. The Plan says medical day care is covered by the Medicaid portion of the enrollee's plan. Therefore, we decided that the Plan does not have to pre-approve adult day care services to be provided under the Medicare portion of the enrollee's plan coverage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mouth swabs for the enrollee.You asked the Plan to pre-approve the swabs. You say that this is medically necessary.The Plan denied your request. The Plan says these are not used to treat a medical illness.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve mouth swabs for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. Yousay that the enrollee would benefit from daily skilled care.The Plan denied your request. The Plan says the enrollee is medically stable and has no daily nursing needs and could be managed with less than daily therapy.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 93 year old female admitted to the hospital with an exacerbation of COPD and respiratory failure. From a nursing perspective, the beneficiary received oral, inhaled and ophthalmic medications. The beneficiary had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a supervision/stand by assist to contact guard assist level with functional mobility including gait to 80 feet with a rolling walker. The beneficiary required varying assist with ADLs.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. However, skilled therapy is not required on a daily basis. This beneficiary 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 admission have not been met.Therefore, we decidedthat the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the round trip non-emergency ambulance provided October 15, 2019 to October 29, 2019.
You asked the Plan to pay for the non-emergency ambulance. You say that you are appealing the necessary ambulance service that has been denied. The letter from you doctor explains why you had to have the gurney. The Plan denied your request. The Plan says transportation to doctor's office is not covered by the plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the round trip non-emergency ambulance provided October 15, 2019 to October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox injections for the enrollee.You asked the Plan to pre-approveBotox. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not being requested for a medically accepted indication.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 Botox. Our reviewer says that Botox is not medically reasonable and necessaryfor the enrollee in this case. The enrollee is noted to have chronic rectal pain, for which Botox is being requested. There is no evidence that the enrollee has a neurologic condition resulting in spasticity or dysfunction. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Botox.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox injections for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips
You asked the Plan to pre-approve additional routine transportation. You say that it is extremely important for the enrollee to have transportation to and from the dialysis center. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not covered by the Plan.
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 a maximum of 60 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 22, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that the doctor wanted to make sure the polyp was removed. You say that this should be covered as preventive.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to itsenrollees 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 $300 copayment for ambulatory surgical center and outpatient hospital visits.You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that polyps were removed which makes this 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 colonoscopy provided on October 22, 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 this is medically necessary.The Plan denied your request. The Plan says alternate settings, such as SNF, outpatient setting, or home health care, should be reviewed.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 functional 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from October 24, 2019 to October 25, 2019.You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that self-administered drugs are not covered under Part B.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 pay for the self-administered drugs provided from October 24, 2019 to October 25, 2019.Benefits for these drugs 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for12 physical therapy visits over 6 weeks.You asked the Plan to pay for the 12 physical therapy visits. You say that the records provided support the need for additional physical therapy visits.The Plan denied your request. The Plan says the records indicate that the enrollee has been treated by physical therapy for low back pain since July 19, 2019. The Plan says that the enrollee has not attended any therapy for over a month. The Plan says that the records from the physical therapist indicate that there is a plan to transition the enrollee to a home exercise program.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 12 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional supervised therapy visits are not generally accepted as specific and effective therapy for the patient's condition. The enrollee has had extensive physical therapy for this condition and should be able to transition to an independent home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 12 physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pay for12 physical therapy visits over 6 weeks