Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Minimed Guardian Sensor 3 Continuous Glucose Monitor (CGM) Sensor.
You asked the Plan to pre-approve a Minimed Guardian Sensor 3 Continuous Glucose Monitor (CGM) Sensor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested sensor is for a model of a CGM that is not FDA-approved as being a therapeutic continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The file shows the requested sensor is for a model CGM that is not FDA-approved as being a therapeutic CGM. Based on this information, we decided that Medicare rules for coverage of a Minimed Guardian Sensor 3 Continuous Glucose Monitor (CGM) Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Minimed Guardian Sensor 3 Continuous Glucose Monitor (CGM) Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe epidural injection provided on September 24, 2019.You asked the Plan to waive the copayment forthe epidural injection. You say that you have been getting these shots for years and never had a copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 per day for outpatient procedures and services. You have been asked to pay a $50 copayment for the epidural injection. The epidural injection falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe epidural injection provided on September 24, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on June 11, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that the blood work was ordered ahead of your physical exam on June 21, 2019. You say you should only be responsible for one copayment because more laboratory work was order on the date of your physicalThe 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 $20 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is lessthan the $20 copayment for laboratory work.You have been asked to pay a $18.67 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forlaboratory work provided on June 11, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveambulance transport to the IRF in Kentucky.You asked the Plan to pre-approvethe ambulance transport. You say that you want to be closer to family.The Plan denied your request. The Plan says this is not the nearest facility.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file andMedicare rules. Ambulance transport is only covered to the nearest facility that can provide the necessary care. The requested facility in Kentucky is not the nearest facility that can provide the approved IRF care. Based on this information, we decided that Medicare rules for coverage of the ambulance transport have not been met.Therefore, we decided that the Plan does not have to pre-approveambulance transport to the IRF in Kentucky.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on September 11, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that this is the only doctor you can find that will
prescribe you suboxene in your area. The Plan denied your request. The Plan says no prior authorization was
obtained for these services. The Plan says that there are multiple pain management providers available that are
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 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 a specialist office visit provided on September 11,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuroelectrodes implantation 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 this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare requires the psychological evaluation to be conducted by either a psychiatrist or a license psychologist. A social worker/mental health counselor does not meet the criteria and this is beyond their scope of practice. Secondly, the enrollee does not have an approved indication for a spinal cord stimulator. The requested procedure is 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 neuroelectrodes implantation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole for the enrollee. 

You asked the Plan to pre-approve Pantoprazole. You say that the enrollee is stable on the medication. The Plan denied your request. The Plan says the medication does not fall under the Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole for the enrollee. 
Benefits for Pantoprazole 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGeneSight genetic testing.You asked the Plan to pre-approveGeneSight genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve GeneSight genetic testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. There is no evidence to support that the requested service is medically reasonable or necessary to diagnose, treat or otherwise manage the enrollee's condition(s).Review of the file shows that the plan uses Local Coverage Determination (LCD) L36799 to support their denial. However, this LCD is not effective for the enrollee's home state of New Mexico. Therefore, we cannot use this LCD to substantiate our decision.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GeneSight genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approveGeneSight genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemyocardial perfusion imaging (78452).You asked the Plan to pre-approvemyocardial perfusion imaging. You say that this should be covered.The Plan denied your request. The Plan says a similar test has been performed and the results have not beensubmitted.The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging is covered when one of the above listed indications are present.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 myocardial perfusion imaging. Our 
reviewer says that the requested service is not medically necessary at this time. Our physician reviewer found based on the records,you have increased coronary risk but no documented symptoms suggestive of coronary ischemia, no documented abnormal cardiac findings on physical exam and no documented electrocardiographic changes concerning for ischemia. In this circumstance the documentation does not support the medical necessity for nuclear stress testing. Hypertension in isolation is not an accepted indication for nuclear stress testing. Coverage criteria for nuclear stress testing are not met since there are no documented covered indications for the procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met.Therefore, we decided that the Plan does not have to pre-approvemyocardial perfusion imaging (78452).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 28, 2018 to October 30, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient services were expected for greater than the two-midnight rule as it was medically necessary.The Plan denied your request. The Plan says that although patient history supports observation care,criteria was not met for inpatient care under seizures. The documentation supports observation services with no further seizures noted during the hospital stay.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are metin this case. Our physician reviewer found that the member presented after reportedly having a seizure. The neurologist on-call consulted in the emergency department (ED) pending further recommendations. The member was admitted with seizure, hypomagnesemia and hypokalemia. During this admission, she was started on Keppra. The member was discharged home on October 30, 2018. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofacute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided October 28, 2018 to October 30, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 as LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH at this time. The enrollee can remain at the current acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of care for any ongoing long-term care 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 thePlan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approvehome health aide services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 pre-approve home health aide services. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found the enrollee is not currently receiving home health skilled nursing or skilled therapy services. The home health order does not indicate what assistance is required. Based on available records, the enrollee does not meet criteria for coverage of the requested home health aide services. The records do not document any skilled nursing or skilled therapy needs. The home health aide services are not reasonable and necessary for the treatment of the enrollee's illness or injury by the skilled professional staff.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to waive the copayment forthe duplex scan provided on August 12, 2019.You asked the Plan to waive the copayment forthe duplex scan. You say that you were informed you would not have a copayment. You say that you should not be responsible.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 does not say in clear and accurate terms how much you should expect to pay for other outpatient diagnostic tests provided at a specialist's office. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $35 copayment for the duplex scan. The Plan contract does not clearly say how much enrollees must pay for other outpatient diagnostic tests. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan does not have to waive the copayment forthe duplex scan provided on August 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the enrollee is not at her baseline to return home independently.The Plan denied your request. The Plan says that the enrollee appears to have reached a functional level where additional therapies at Part A intensity will likely not change her functional level or outcome.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found thatthe enrollee's condition does not meet Medicare criteria for continued SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on August 14, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on August 14, 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 a need for increased monitoring, increased wound care, and the need of daily physician involvement. You say that the enrollee's clinical summary and the clinical documentation provided support the need for LTACH care. The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care 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 the enrollee's ongoing care needs include respiratory support with oxygen supplementation and BiPAP support, neurologic monitoring, surveillance laboratory studies, hemodialysis, wound vacuum care, 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transfer from the  current acute hospital.You asked the Plan to pre-approvethe requestedtransfer. The Plan denied your request. The Plan says there is no medical reason to move the enrollee from a hospital that is capable of treating him.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 requested transfer. Our physician reviewer found that the enrollee presented to the emergency department with post-operative wound infection on his back. Additionally, the enrollee was diagnosed with a urinary tract infection. He was admitted to the hospital and received vigorous resuscitation with intravenous fluids, antibiotics, and wound care. Documentation supports the enrollee has improved, but continues with persistent bacteremia. The documentation does not support that the enrollee in this case requires services at the second facility that are not available at the acute care hospital where he is currently receiving 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 the requested transfer have not been met. Therefore, we decided that the Plan does not have to pre-approvea transfer from the  current acute hospital.