Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic tests. You say that this test is covered by Medicare and should be paid at the established rate. The Plan denied your request. The Plan says the denial of payment for these tests is correct, because prior authorization is required for genetic testing but was not obtained for these tests.
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 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 September 5, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve responsive cortical stimulation.
You asked the Plan to pre-approve responsive cortical stimulation. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee's diagnosis is not covered for this procedure.
The Plan must follow Medicare rules. We reviewed the National Coverage Determination (NCD) cited by the Plan and have found that it is not applicable to the requested services. 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 responsive cortical stimulation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the responsive cortical stimulation requested in this case is distinct from the type of deep brain stimulation used in treatment of Parkinson's Disease and Essential Tremor. Responsive neurostimulation (RNS) shares some features with deep brain stimulation but is differentiated by its use of direct cortical stimulation and by its use in both monitoring and stimulation. The responsive neurostimulation system provides stimulation in direct response to detection of specific epileptiform patterns, while deep brain stimulation provides continuous or intermittent stimulation at preprogrammed settings. This technology is approved by the Food and Drug Administration (FDA) for use in the enrollee's condition. The evidence to support this technology comes from a randomized controlled trial and case reports. The technology is otherwise in widespread use and is generally accepted as being safe and effective for use in the management of the enrollee's condition. Therefore, the implantation of a responsive neurostimulator would be consisted with the generally accepted standards of care and is 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 responsive cortical stimulation have been met. Therefore, we decided that the Plan has to pre-approve responsive cortical stimulation.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora raised toilet seat purchased on September 13, 2019.You asked the Plan to pay fora raised toilet seat. You say that you are requesting reimbursement of the raised toilet seat you purchased.The Plan denied your request. The Plan says this is a personal comfort item, it is not reasonable and necessary according to the standards of Original Medicare.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 pay fora raised toilet seat purchased on September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient psychiatric care. You asked the Plan to pre-approvethese services. You say that you are requesting reconsideration of the Plan's denial.The Plan denied your request. The Plan says the acute inpatient psychiatric careis not medically necessary. The appropriate alternative level of care would be behavioral residential.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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-approvethese services. Our reviewer says that the patient does not meet criteria for coverage of acute inpatient psychiatric care. Our physician reviewer found the enrollee did not appear to require inpatient mental health treatment as she was cooperative and compliant with care without any aggressiveor abnormal behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or were for the purpose of a diagnosis. Based upon review of the records provided,the patient does not meet criteria for coverage of acute inpatient mental health treatment as she was not shown to be a danger to herself or others and did not have auditory or visual hallucinations.  We lookedat 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-approveacute inpatient psychiatric care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility care (SNF).
You asked the Plan to pre-approve these services. You say that inpatient skilled nursing facility care is medically necessary as you have mobility issues, shortness of breath, and a urinary tract infection. The Plan denied your request. The Plan says you do not meet criteria for coverage of a SNF inpatient admission.
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 these services. Our reviewer says that you do not meet criteria for coverage of inpatient skilled nursing facility care. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis. While you may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy in a SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility care (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services beyond February 18, 2020.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 the records show that you were admitted to the hospital with recurrent depressive disorder with psychosis and cocaine use disorder. You were cooperative and had no suicidal or homicidal ideation. You did not have any auditory or visual hallucinations. It is not medically necessary to have psychiatric care provided at the inpatient level beyond the dates in question, as you are not showing aggressive behaviors. It does not appear that active treatment is taking place. The continued inpatient services are 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 inpatient psychiatric services beyond February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Telephone evaluation and management provided on July 3, 2019.
You asked the Plan to pay for the telephone evaluation and management services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for telephone evaluation and management services provided on July 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 20, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were informed you would not have any out-of-pocket fees. You say that you wouldn't have had the procedure if you had to pay for it. 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 $400 copayment for Medicare-covered, in-network, outpatient hospital surgery services. You have been asked to pay a $400 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 is considered a diagnostic 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 for the colonoscopy provided on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician visit. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 September 9, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi for the enrollee.
You asked the Plan to pre-approve Aloxi. The Plan denied your request. The Plan says routine costs associated with a clinical trial is the responsibility of Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Aloxi as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Aloxi for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic Digital Breast Tomosynthesis
(3D Mammogram) (77061) provided on October 25, 2019.
You asked the Plan to waive the copayment for the 3D Mammogram. You say that you were charged a $60
copayment for an ultrasound you never received. The Plan denied your request. The Plan says the copayment
was for the 3D Mammogram, not an ultrasound.
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 $60
copayment for Diagnostic Imaging.
You have been asked to pay a $55.93 copayment for the 3D Mammogram. The 3D Mammogram falls within
the Diagnostic Imaging benefit category. The Medicare allowable amount of $55.93 is less than the $60
copayment listed in the EOC. 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 a diagnostic Digital Breast
Tomosynthesis (3D Mammogram) (77061) provided on October 25, 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided on October 10, 2019.
You asked the Plan to waive the copayment for the specialist services. You say that it was never explained to you that there would be a charged connected with the trainer and you were told that everything would be covered under the insurance company. 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 records show that face-to-face training was requested and performed on October 10, 2019; the training included education on the equipment, supplies, & preparation, testing procedure, reading & reporting results, problem solving, and cleaning. This is considered a specialist office visit which does have a $50 copayment when performed in the home. 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 specialist services provided on October 10, 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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not require physician supervision by a rehabilitation physician with face to face visits at least 3 days per week.
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. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on August 29, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare does not pay any provider or supplier other than the hospital for services furnished to the beneficiary while an inpatient in hospital, and this takes precedence over the claim system denial. These services and CPT codes are statutorily excluded by Medicare. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services in the facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to the facility. Payment for this service is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is necessary. The Plan denied your request. The Plan says the enrollee currently has portable oxygen tanks that are working appropriately, therefore coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a stationary oxygen concentrator and portable E oxygen tanks. A stationary oxygen concentrator and portable E oxygen tanks serve the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH service.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee's ongoing treatment can be safely done in the current acute care setting.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 physician reviewer found that in the case of this enrollee, recent hospital care notes reveal that although they were still being treated with IV antibiotics for pneumonia. There was evidence of ongoing improvement with them being afebrile and normalizing white blood count, suggesting they will not require acute care services for more than 25 days to justify transfer to LTACH. There were no services needed at the proposed LTACH which were not already being provided and covered at the current facility. Therefore, this request for LTACH transfer will be considered not medically necessary 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 LTACHservices have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.