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

We decided that the Plan does not have to pre-approvegradient compression stockings (A6549) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvegradient compression stockings. You say that your son needs to wear these custom compression leggings andneeds to use them every day. Your son has lymphedema and without these stockings, he will become crippled as he gets very swollen legs. The stockings need to be made custom and not all durable medical equipment (DME) companies make them. Biohorizon has already measured him and can provide them.The Plan denied your request. The Plan says your primary care physician (PCP) may refer you to an out-of-network provider when your medical needs cannot be met through the Plan's network. In some cases, your PCP will need to get authorization from 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 pre-approve care from out-of-network providers only in cases involvingemergencies, 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. The Plan provided you with the name of an in-network provider who does provide custom stockings. 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-approvegradient compression stockings (A6549) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forautomatic external defibrillator (CPT Code K0606) provided from July 3, 2019 through September 3, 2019.You asked the Plan to waive the coinsurance forthe DME. You say that you were told this was covered by your insurance.The Plan denied your request. ThePlan 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 fileshow that you received automatic an external defibrillator (CPT Code K0606) provided from July 3, 2019 through September 3, 2019. You are asked to pay 15% coinsurance per date of service for the DME. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forautomatic external defibrillator (CPT Code K0606) provided from July 3, 2019 through September 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that IRFcare is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of IRF care.The Plan must follow Medicare rules. The rules say that the 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 that thecomplexity of the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical and occupational therapy,but the patient does not require this on an intensive rehabilitation facility therapy programlevel 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 anacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve 3 PT visits. We decided that the Plan does not have to pre-approve the remaining 7 PT visits requested.
You asked the Plan to pre-approve 10 additional PT visits. You say that skilled therapy is required to provide the enrollee with guidance for exercising without pain. The Plan says that 10 additional PT 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 denying the request for 10 additional PT visits. Our reviewer says that the documentation supports 3 additional visits to be medically necessary. Our physician reviewer found three visits will provide adequate time to safely transition the enrollee to a home exercise program, with education on activity avoidance and modification of exercise to reduce pain while improving strength and range of motion. More than 3 visits are not 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 3 PT visits have been met. We also decided that the Plan does not have to pre-approve the remaining 7 PT visits requested.
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. The Plan denied your request. The Plan says LTACH admission is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that in the case of this enrollee, although ICU admission, antibiotics, and hemodialysis was needed in the acute care hospital setting, improvement is noted including moving from IV antibiotics to oral, uneventful dialysis, and stable vitals. The proposed transfer to a LTACH would not provide any new and needed treatment to improve the outcome, and current care is covered and appropriate until further improvement is noted to warrant discharge to a lower level of care, which should be in less than 25 days based on the most current notes. Therefore, this request for LTACH services will be considered not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit you received on October 31, 2019.
You asked the Plan to pay for the office visit. You say that you shouldn't be responsible for more than your chiropractic copay. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Services other than manipulation when performed by a chiropractor are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the office visit you received on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle LibreContinuous Glucose Monitoring system.You asked the Plan to pre-approvea continuous glucose monitorand supplies. You say that the enrollee is not able to check sugar levels and needs a continuous glucose monitor to control blood sugar.The Plandenied your request. The Plan says the record shows the enrollee is not insulin treated or checking blood glucose 4 or more times a day.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. Medical records show the enrollee is not on insulin. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network physician services you received on September 30, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was processed per your plan 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). Your contract with the Plan clearly says that you must pay a 40% coinsurance for out-of-network physician services. The file shows that you received an office visit from an out-of-network provider. You were charged $66.83 which allowed you to reach your deductible. You were then charged $21.66, which is 40% of the remaining cost. The services fall within the physician 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 pay for the out-of-network physician services you received on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 POV.
You asked the Plan to pre-approve a replacement POV. You say that the enrollee's scooter is broken and needs replacing. The Plan denied your request. The Plan says the enrollee received a POV on March 9, 2016 that can be repaired.
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 enrollee's current scooter is still within the 5-year RUL and the documentation submitted does not show that the scooter is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the replacement scooter at issue. Therefore, we decided that the Plan does not have to pre-approve a Group 1 POV.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnbrel SureClick for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has tried and failed Methotrexate.The Plan denied your request. The Plan says that this is not covered under the enrollee's Part B plan.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-approveEnbrel SureClick for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the information in the medical records suggest that the medical problems could be cared for on an outpatient basis.
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 is currently undergoing treatment at an ACH for osteomyelitis of the ankle. The enrollee is receiving wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. 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 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 the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Human Papillomavirus (HPV) vaccine you received on September 24, 2019.You asked the Plan to pay forthe vaccine. You say that it's important to get vaccines before it's too late to get protections.The Plandenied your request. The Plan says vaccines and their administration fee are a Part D covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay forthe Human Papillomavirus (HPV) vaccine you received on September 24, 2019.Benefits for the vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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. The Plan denied your request. The Plan says LTACH admission is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a heart attack. The enrollee underwent an interventional catheterization and temporarily had an intra-aortic balloon pump. The enrollee was transiently intubated/ventilated, but has since been extubated and is no longer on a ventilator. 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-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 the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome infusion therapy services provided to the enrollee from February 15, 2019 to March 25, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis should be coded with a payable code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the definition of HCPCS code S9328 is "home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem."We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. Thisindicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forhome infusion therapy services provided to the enrollee from February 15, 2019 to March 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional home health aide hours for the enrollee.You asked the Planto pre-approvethe additional hours. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare has limited the number of hours per week of skilled nursing care to 35 hours per week.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 the additional hours. Our reviewer says that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found the additional hours of home health care services are not medically necessary per Medicare guidelines. The enrollee must require skilled nursing or skilled therapy home services in order to receive home health aide services. The services provided by the home health aide must meet Medicare guidelines definition of "part-time or intermittent." The enrollee is approved skilled nursing for 35 hours a week therefore the request for an additional 120 hours per week of home health aide services exceeds this 35 hours and is not 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 the additional hours have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional home health aide hours for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 6, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 pay for drug testing services provided to the enrollee on May 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued of skilled nursing facility (SNF) care.You asked the Plan to pre-approvecontinued SNF care.The Plan denied your request. The Plan says continued SNF care is not medically necessary.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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 Medicarerules for coverage of continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued of skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic nuclear medicine provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for diagnostic nuclear medicine. You say that these services were medically necessary. You say that you would like this reprocessed for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.
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 diagnostic nuclear medicine provided on October 14, 2019 by an out of network (OON) provider.