Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second-opinion consultation regarding your cancer diagnosis and treatment plan to be provided by an out-of-network provider.
You asked the Plan to pre-approve a second-opinion consultation. You say that the requested service is a necessity for your care. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 involving emergencies, 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second-opinion consultation regarding your cancer diagnosis and treatment plan to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Vitamin D 25 hydroxyl testing provided to the enrollee from September 24, 2020, to November 19, 2020.
You asked the Plan to pay for the testing. You say that you were not notified of any changes to the policy. The Plan denied your request. The Plan says that this type of testing is covered up to three times per year.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. These services were provided by a contract provider. The file does not show that the Plan provided notice that the testing would not be covered. There is no citation in the Evidence of Coverage about this type of testing only being covered three times per year. Under Medicare rules, this means the testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for Vitamin D 25 hydroxyl testing provided to the enrollee from September 24, 2020, to November 19, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: 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 you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
While you may need physical and/or occupational therapy, there is no documented need for an intensive
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in
- and benefit from - the intensive rehabilitation therapy program provided 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82542, 84228, G0483) provided on March 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 had network providers available who could have provided 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 laboratory services (82542, 84228, G0483) provided on March 11, 2021 by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve routine transportation. You say that you need to see this provider to determine what causes your severe pain for future treatment. The Plan denied your request. The Plan says the denial of authorization for routine transportation is correct, because transportation to this destination would be over 50 miles per one-way trip which is not covered by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 50 miles per one-way trip.
We looked at your request, the records in the case file, and the rules. Transportation to this destination would exceed 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator for the enrollee.
You asked the Plan to pre-approve a portable home ventilator. You say that the enrollee needs the ventilator to be able to breathe. The Plan denied your request. The Plan says that the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a portable home ventilator. Our reviewer says that a portable home ventilator is not medically reasonable and necessary for the enrollee. The requested pressure settings with target tidal volume can be met with the use of a bilevel positive airway pressure (BIPAP) device. The requested device is being used in the BIPAP mode rather than being used as a home ventilator.
The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable home ventilator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from August 25,
2021, onward.
You asked the Plan to pre-approve inpatient psychiatric care. You say that ongoing inpatient psychiatric care is
medically necessary The Plan denied your request. The Plan says they agree that the inpatient psychiatric care
was medically necessary through August 24, 2021, but after this date the services were no longer necessary on
an inpatient basis and the enrollee could be moved to 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 inpatient psychiatric care. Our reviewer says that the health Plan's denial of continued inpatient psychiatric services is appropriate in this case. Our physician reviewer found that based on a review of the provided records, it is no longer expected that this enrollee will improve in a reasonable period of time as they do not have suicidal or homicidal ideation noted and deny any auditory or visual hallucinations. The enrollee is compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have continued psychiatric care at the acute inpatient level rather than at a lower level of care beyond the dates covered by the Plan. It does not appear that active treatment is taking place beyond the dates in question, or that these services are reasonably expected to improve the enrollee's condition or are for the purpose of diagnosis. Based upon review the records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question.
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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services from August 25, 2021, onward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that physical therapy has kept
him out of the hospital over the last several months. You say that it is an appropriate investment to keep the
patient out of the hospital and request therapy through the remainder of the year. The Plan denied your request.
The Plan says physical therapy is 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 to pre-approve 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the patient has had 20 prior
outpatient therapy visits and the unique skills of a professional therapist are not required to safely and
effectively provide ongoing 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 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that a lower level of care cannot provide a total interdisciplinary approach needed. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that the enrollee was admitted to the acute care hospital for splenectomy, repair of diaphragmatic rupture, non-surgical management of rib fractures and sternal fracture after motor vehicle collision. She was discharged home and has ongoing pain and trouble ambulating.
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Zinc air batteries provided on November 22, 2019.
You asked the Plan to pay for Zinc air battery for use with cochlear implant device. You say that you had an authorization for the batteries. The Plan denied your request. The Plan says the number of units allowed for this service under Medicare rules has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.
We find that the authorization was effective until July 30, 2018. Based on this information, we decided that Medicare rules for coverage of Zinc air battery for use with cochlear implant device have not been met. Therefore, we decided that the Plan does not have to pay for Zinc air batteries provided on November 22, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 17, 2021 and March 25, 2021.
You asked the Plan to pay for the office visit (99202) and chiropractic manipulative treatments (98942). You say that you thought you would only have a $20 copayment for services. The Plan denied your request. The Plan says the provider did not submit the claim correctly and office visits provided by a chiropractor are never covered.
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. The chiropractic manipulative treatments were submitted incorrectly and cannot be paid as billed. The provider is only billing you for the un-covered office visit of $60. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on March 17, 2021 and March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory viral panel with 12 to 25 targets (87633) provided on August 17, 2020.
You asked the Plan to pay for a respiratory viral panel with 12 to 25 targets. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that tests that include more than 5 viral pathogens are non-covered, including code 87633. We looked at the file and Medicare rules. The testing at issue is excluded from coverage. Based on this information, we decided that Medicare rules for coverage of a respiratory viral panel with 12 to 25 targets have not been met. Therefore, we decided that the Plan does not have to pay for a respiratory viral panel with 12 to 25 targets (87633) provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 22, 2020.
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 services were not billed correctly.
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 file shows that the services were billed with POS code 23 for an emergency room. This is an inappropriate place of service for the office visit. Therefore, we decided that the Plan does not have to pay for the office visit rendered on September 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that your back hurts constantly but physical therapy every 5 weeks keeps it aligned. You say that you need this maintenance and do not want this taken away. The Plan denied your request. The Plan says physical therapy is 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 to pre-approve 12 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy and were instructed in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 12 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica.
You asked the Plan to pre-approve Lyrica. You say that the enrollee has been able to control her symptoms well with the use of Lyrica. The Plan denied your request. The Plan says Lyrica to be administered at home is not covered under the Part 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 Lyrica.
Benefits for Lyrica 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical assistant for a treatment of thigh fracture (27236) performed on February 27, 2021.
You asked the Plan to pay for a surgical assistant for a treatment of thigh fracture. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for a surgical assistant have not been met because the surgical assistant in this case is not a physician, PA, NP, or CNS.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for a surgical assistant for a treatment of thigh fracture (27236) performed on February 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 2020.
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 billed incorrectly.
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 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on May 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that that you are not back to your previous level of function and would benefit from SNF level of care. The Plan denied your request. The Plan says that the records do not support the need for daily therapy in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 that your condition does not meet Medicare criteria for 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-approve skilled nursing facility (SNF) services.