Persius/hicric huggingface dataset:
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 services are medically necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 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 based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by acute physical medicine and rehabilitation (PMR) or acute rehab nursing care. She may benefit from further physical therapy (PT) and also occupational therapy (OT) but does not require an intensive therapy program. She has no endurance and will not make a significant improvement in a predictable period of 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the enrollee has chronic foot pain. You recommended the requested orthotics to help treat the enrollee's foot pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued inpatient psychiatric services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee can be treated at a lower level of care.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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon review therecords provided for the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 10, 2020 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment awaiting placement.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 Plandoes not haveto pre-approvecontinued inpatient psychiatric services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mouth guard (D9945). You asked the Plan to pre-approve mouth guard. You say that you feel that the mouth guard should be covered because you have jaw pain and your dentist feels that you need it. The Plan denied your request. The Plan says this item is not a covered benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Services Not Covered on page 157, specifically states that bite splints and dental appliances are not covered under any condition Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve mouth guard (D9945)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveC-Pap and heated humidifier (E0601, E0562).You asked the Plan to pre-approvethe C-PAP and heated humidifier. You say that the claim should be paid.The Plan denied your request. The Plan says there is no documentation that the heated humidifier is lost, irreparably damaged, or your medical condition changes such that the current equipment no longer meets your needs.MVP must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment in 2016.  This is still within the 5-yearRUL and the documentation submitted does not show that the equipment is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue.  While there is a note that it is broken, it has not been shown to be irreparably damaged. Based on this information, we decided that Medicare rules for coverage of the C-PAP and heated humidifier have not been met.Therefore, we decided that the Plan does not have to pre-approveC-Pap and heated humidifier (E0601, E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on June 11, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99239 is not supported.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 CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 forthe hospital discharge services rendered on June 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 1, 2019 by an out of network provider You asked the Plan to pay forX-Ray reading. You say that you are appealing with medical records, and this test was referred to you by the treating physician at the orthopaedic clinic.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 the referring physician is also out-of-network with 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 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 forthe medical services provided on April 1, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on June 4, 2019.You asked the Plan to pay forlab tests. You say that Medicare covers these charges and they should be paid.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the Plan does not cover laboratory tests performed byout-of-network providers even if the tests were ordered by an in-network provider.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 specify whether the ordering physician is in-network or out-of-network with the Plan. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that their decision to deny payment for these tests is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay forlaboratory testing provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on June 25, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 careand pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided thatthe Plan does not have to pay forahospital outpatient clinic visit provided on June 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 30-74 minutes of critical care services (99291) provided on August 18, 2019.You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service.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 CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not include a critical care note of 30-74 minutes for the billed date of service. Based on this information, we decided thatMedicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the first 30-74 minutes of critical care services (99291) provided on August 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVyzulta.You asked the Plan to pre-approveVyzulta. You say that this is medically necessary.The Plan denied your request. The Plan says that drug coverage is limited to Medicare Part B drugs.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-approveVyzulta.Benefits for Vyzultamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe periodontal scaling and root planing (D4341) for the upper left and lower left quadrants provided on June 4, 2019.You asked the Plan to pay the full amount forthe dental services. You say that the services were approved as covered on April 25,2019.The Plan denied your request. The Plan says the services were correctly paid at the 50% cost share amount.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and the periodontal scaling and root planing is a covered service, there is a 50% cost share that still applies to the services.Therefore, we decided that the Plan does not have to pay the full amount forthe periodontal scaling and root planing (D4341) for the upper left and lower left quadrants provided on June 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKetamine.You asked the Plan to pre-approveKetamine. You say that the requested Ketamine treatment is medically necessary due to depression.The Plan denied your request. The Plan says coverage criteria is not met.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ketamine. Our reviewer says that the Ketamine treatments are not medically appropriate. Our physician reviewer found based on the records and the literature provided by the manufacturer, this procedure is not indicated by the FDA for the treatment of Depressive Disorders. The use of this procedure is considered off label. Based on review of the records provided and the literature provided on the use of this procedure, it does not appear that this procedure is considered medically necessary for the treatment of depressive disorderWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine have not been met.Therefore, we decided that the Plan does not have to pre-approveKetamine.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria as the enrollee did not have a qualifying three day inpatient hospital stay.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. In order to receive coveredpost hospital SNF services, the enrollee must have a medically necessary inpatient stay for at least three consecutive calendar days.We looked at the file and Medicare rules. The review shows that the enrollee was admitted under an Observation level of care and signed the Medicare Outpatient Observation Notice. The medical records provided show the enrollee was not admitted as inpatient to the hospital for three consecutive calendar days. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveabiraterone 250mg tablets.You asked the Planto pre-approvethe abiraterone tablets. You say that the enrollee requires this medication.The Plandenied your request. The Plansaysthis oral drug is not covered by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveabiraterone 250mg tablets.Benefits forthe abiraterone tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ashower chair.You asked the Plan to pre-approvea shower chair. You say that you have not been able to shower in a long time. You say that you have lost a lot of power in your right leg and need the shower chair in order to bathe.The Plan deniedyour request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Prescription Eyeglasses obtained September 4, 2019
You asked the Plan to pay for the eyeglasses. You say that the eyewear should be covered. The Plan denied your request. The Plan says coverage is only provided for services obtained from in-network vision providers.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The contract provides a $150 allowance towards prescription eyeglasses only when obtained through in-network vision centers.

We looked at the file and the Plan's rules. The eyeglasses were obtained from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for Prescription Eyeglasses obtained September 4, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on August 22, 2018.You asked the Plan to pay fortrain of four testing. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says this service is bundled into the payment of the primary service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the medical record. Specifically, CPT code95999 is not supported for train of four testing. According to CPT rules, train of four is included in other intraoperative neuromonitoring procedures and is not reported separately. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on August 22, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEstradiol for the enrollee.You asked the Plan to pre-approveEstradiol. You say that this is needed for treatment of the member's menopausal and perimenopausal disorder.The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEstradiol for the enrollee.Benefits for Estradiolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that your ability to balance,stand and walk is impaired and it is dangerous for you to move from your wheelchair into the shower. You say that there is a risk of falling in the shower which could lead to injury and potentially higher medical costs.The Plan denied your request. ThePlan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 19, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 physician's services provided on August 19, 2019.