Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 31, 2020 with hyperkalemia, acute kidney injury, hypotension, and cancer-related pain. It is documented on February 19, 2020 that he has not been able to tolerate three hours of therapy per day. He has cancer-related fatigue and generalized weakness. While he may require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, the records do not support that he would be able to fully participate in and benefit from an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Synvisc One injection (J7325).
You asked the Plan to pre-approve the Synvisc One. You say that you are currently unable to walk long distances and this injection has worked. The Plan denied your request. The Plan says the record does not show that you have had noticeable improvement after the last injection.
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 Synvisc One. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you did not receive significant pain relief from the prior injection. 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 Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat Synvisc One injection (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair accessories for the enrollee.You asked the Plan to pre-approvethe requested accessories. The Plandenied your request. The Plan says the requested items are non-covered.The Plan must follow Medicarerules. Medicare rules say that wheelchair options and accessories are covered only under certain medical indications. The file shows that an attendant control was requested for the enrollee's power wheelchair. We looked at the file and Medicare rules. The records show that a beneficiary-operated control has been approved by the plan. If an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.An Omni Display was requested for the wheelchair. The records show that an expandable control system was approved by the plan. The Omni display is included in the expandable controller. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313.A breath tube kit ear mount and egg switch mount were requested for the wheelchair as identified by code K0108. The rules say that items must be reported with appropriate codes. Code E1028 is used for swingaway hardware used with remote joysticks or touchpads, swingaway or flip-down hardware for head control interfaces E2327-E2330, and swingaway hardware for an indicator display box that is related to the multi-motor electronic connection codes E2310 or E2311. Based on this information, we decided that Medicare rules for coverage of the requested accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair accessories for the enrollee.
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 medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 patient does require skilled physical therapy and occupational therapy but based on the medical records provided the patient does not require treatment in 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Axumin PET CT scan (78816).
You asked the Plan to pre-approve an Axumin PET CT scan (78816). You say that the requested PET CT scan is medically necessary. The Plan denied your request. The Plan says the requested PET CT scan does not meet criteria.
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 an Axumin PET CT scan (78816). Our reviewer says that the requested Axumin PET CT scan is not medically necessary. Our physician reviewer found the enrollee is with recurrent prostate cancer. A CT scan shows adenopathy. Per the Axumin package insert, Axumin is approved with PET CT scan for men with suspected prostate cancer recurrence based on elevated PSA following prior treatment. Based on the documentation provided, this enrollee has documented recurrence prostate cancer, not suspected. Imaging with bone scan and CT chest can be done to complete staging evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Axumin PET CT scan (78816) have not been met. Therefore, we decided that the Plan does not have to pre-approve an Axumin PET CT scan (78816).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided September 12, 2019 to September 19, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the patient's condition warranted inpatient care. The Plan denied your request. The Plan says that the notes do not show that the patient met medical necessity for inpatient level of care.
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 met in this case. Our physician reviewer found the enrollee presented on September 12, 2019 with complaints of weakness and frequent falls. She was admitted for management of anemia, diabetes with hyperglycemia and unsteady gait. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department 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 of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided September 12, 2019 to September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says Medicare criteria for inpatient mental health care are not met.
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 inpatient mental health care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 12, 2020 forward. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was being cooperative in treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the bitewing x-rays (D0272), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 11, 2019.
You asked the Plan to pay for the dental services. You say that you were not properly oriented and informed of the treatments and the costs of the treatments that you received. The Plan denied your request. The Plan says that the frequency limit for bitewings has been exceeded. The Plan also says that the periapical x-rays are not listed as covered services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that you have been adequately notified of the Plan's coverage rules and benefits. Therefore, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the bitewing x-rays (D0272), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee presented to the emergency department on 1/22/20 after a mechanical fall at home, hitting her head on the wall with loss of consciousness. She sustained a right temporal hematoma. Imaging showed no acute intracranial injury. She was found to have a urinary tract infection and was treated with antibiotics and discharged home with home care services on 1/24/20. She now requires minimal assist for activities of daily living and mobility. Based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee had a fall with no new neurological injuriesand was medically stable with no evidence of need for supervision by a physical medicine and rehab physician or needs by acute rehab nursing care. She may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services could have been provided 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 August 8, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services rendered on November 26, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed with an appropriate place of service (POS) code.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 32 for a nursing facility; however, the file does not support that the services were performed in a nursing facility. Therefore, we decided that the Plan does not have to pay for the transitional care management services rendered on November 26, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve several services to include bone marrow aspiration for
the enrollee.
You asked the Plan to pre-approve bone marrow aspiration. You say that bone marrow aspiration is medically
necessary. The Plan denied your request. The Plan says while several of the requested services were approved,
bone marrow aspiration is not covered by Medicare or the Plan.
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 bone marrow aspiration. Our reviewer
says that bone aspiration is not considered medically reasonable and necessary in this case. Our physician
reviewer found bone marrow aspiration remains experimental and is not covered by Medicare. We looked at
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have
to pre-approve several services to include bone marrow aspiration for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe progressive lenses and anti-reflective coating rendered to you on August 3, 2019.You asked the Plan to pay forthese services. You say that the glasses were given after an operation to replace the lens in your eye.The Plan denied your request. The Plan saysthe services are not covered.The Plan must follow Medicare rules. Medicare rules say that progressive lenses are not covered and anti-reflective coating is covered when billed with the KX modifier.We looked at the file and Medicare rules. The services at issue are progressive lenses and anti-reflective coating. The progressive lenses are not covered by Medicare and the anti-reflective coating was not billed with the KX modifier to show medical necessity.Therefore, we decided that the Plan does nothave to pay forthe progressive lenses and anti-reflective coating rendered to you on August 3, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse $500 per ear for hearing aids purchased on July 22, 2019.You asked the Plan to reimburse $500 per ear for hearing aids purchased on July 22, 2019the hearing aids. You say that your EOC states that you are eligible for a $500 reimbursement per ear, with no mention of a network provider.The Plan denied your request. The Plan says that you self-referred to an out-of-network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The hearing aid benefit is not a Medicare benefit. It is a supplemental benefit offered by the plan that reimburses $500 per ear every year.This means that the generic lock-in language in Chapter3 is not sufficient. The limitation on a plan provider must be specifically listed for the hearing aid benefit. It is not, neither in the hearing aid section of the benefits chart (Chapter 4) nor in the exclusions list at the end of the benefit chart.Therefore, we decided that the Plan has to reimburse $500 per ear for hearing aids purchased on July 22, 2019If 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 24, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered to the enrollee on April 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 92921 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. The provider submitted a claim for procedure code 92921 (percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery [List separately in addition to code for primary procedure]). This code has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 25, 2019.