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 documentation provided supports the need for care in an IRF.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.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 andnecessary 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. The enrollee is living at home receiving home health services after a stay in IRF from October 27 -November 13, 2020, after acute hospitalization for a stroke. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medicalrecord supports a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from theintensive 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 decidedthat the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 8, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 June 8, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says these services are available in-network.Medicare rules say that plans can require enrollees to getcare 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-approvemedical services to be provided by an out-of-network provider
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. The Plan denied your request. The Plan says the requested item is not a Medicare 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. 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. 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 these services. Our reviewer says that the services are not medically necessary. Ourphysician reviewer found the enrollee has a history of back pain. The requested spacer is considered experimental in nature, and more research is needed to show safety and efficacy. The services are therefore not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON services. You say that the clinicians are experienced with manual techniques to address cervical pain.The Plan denied your request. The Plan says the requested services are available within the enrollee's plan 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 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, wedecided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approvecataract  surgery  to be provided  by an out-of-network provider.You asked the  Plan to pre-approvethe services.  The  Plan  denied  your  request.  The Plan  says the  services  are available  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 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-approvecataract surgery  to be provided  by an  out-of-network  provider.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rulessay 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 you are living at home receiving home health services after a recent admission for pain from colitis and worsening multiple myeloma. Your medical problems are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Thedocumentation does not support that you require an intensive rehabilitation therapy program provided in an IRF. Your care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the copayment  foroutpatient  hospital  observation  services (G0378 and 71275) provided  on August  12, 2020.You asked the  Plan to waive  the copayment  forhospital  observation.  You say that you  are being  charged  the wrong  amount.The  Plan  denied  your  request.  The Plan  says the  cost share  is correct.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 $200 copayment  for  outpatient  hospital  observation. You  have  been asked to pay a $200 copayment  for  hospital  observation.  This  service  falls  within  the outpatient hospital  observation  benefit  category.  This  means  that  you  have  been asked to pay the correct  amount  based on your  contract  with  the  Plan.  This  cost sharing  is a contractual  obligation  you  agreed to pay when  you  enrolled in  the  Plan.Therefore,  we decided  that  the  Plan  does not  have to waive  the copayment  foroutpatient  hospital observation  services  (G0378 and 71275) provided  on August  12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system for the enrollee.
You asked the Plan to pre-approve a CardioMEMS system. You say that the patient urgently needs this device
and procedure due to her worsening heart failure. The Plan denied your request. The Plan says that this service
is considered experimental and investigational.
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 a CardioMEMS system. Our reviewer
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. In this
circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in
only one randomized prospective trial to help reduce hospital readmission compared to standard medical
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. The device is still considered
experimental or investigational. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for a CardioMEMS system.
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 CardioMEMS system have not been met. Therefore, we decided that the Plan
does not have to pre-approve a CardioMEMS system for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveFlowerAmnioFlo  (Q4177).You asked the  Plan topre-approveFlowerAmnioFlo.  You  say that this  is  necessary  to avoid  a knee operation.The  Plan  denied  your  request.  The Plan  says this  is not  supported  for  your  condition.The  Plan  must  follow  Medicare  rules.  Medicare  rules  say  that  items  and  services  that  are not medically necessary  are not covered.  The  rules  also  say the  information  submitted  by the  supplier  or provider  must corroborate  the documentation  in  the beneficiary's  medical  documentation  and confirm  that  Medicare  coverage criteria  have been met.We looked  at the  fileand Medicare  rules. No medical  records have  been  submitted  by your  provider  to support this  request.  Without  this  information,  it cannot  be verified  whether  Medicare  criteria  have  been met. Based on this  information,  we decided  that  Medicare  rules  for coverage  of FlowerAmnioFlo  have  not been  met.Therefore,  we decided  that  the Plan  does not have to pre-approveFlowerAmnioFlo  (Q4177).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dynasplint system: dynamic adjustable shoulder flexion/abduction/rotation device (E1840).
You asked the Plan to pre-approve the Dynasplint system. You say that you are asking to please review this request for authorization for this enrollee to receive this DME equipment. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of your health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Dynasplint system have not been met. Therefore, we decided that the Plan does not have to pre-approve Dynasplint system: dynamic adjustable shoulder flexion/abduction/rotation device (E1840).
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 would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee required supervision for grooming. The enrollee required maximum
assistance for lower body bathing. The enrollee required minimal to maximum assistance for upper body and
lower body dressing. The documentation does not support that the enrollee requires an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the
enrollee requires an intensive rehabilitation therapy program provided in an IRF. The enrollee's care needs can
be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 waive the copayment for the outpatient surgery you had at an outpatient hospital facility on May 25, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You did not provide an argument in your appeal. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for surgery services in an outpatient hospital facility. You have been asked to pay a $200 copayment for the outpatient surgery. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery you had at an outpatient hospital facility on May 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental surgery procedures (D41899 x 4), the reconstruction of jaw (21248 x 2), the face bone graft (21210), and a lower jaw bone graft (21215).You asked the Plan to pre-approvethe dental services. You say that the enrollee suffers from maxillary and mandibular bone atrophy. You say that the enrollee has been experiencing frequent pain and episodes associated with the mandibular branch of the trigeminalnerve. Youalso say that the requested services are medically necessary.The Plan denied your request. The Plan says the services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicarecoverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that in this instance the primary treatment being provided is addressing dentally related issues, and would seek to improve mastication and also aid in preventing pressure on the mental nerves that are more easily traumatized when eating due to the atrophy of the mandible.  The reviewer found that there is no primary medical condition, eg. a tumor, that is being treated such that the requested procedures would be required to be performed in order to allow for treatment of the primary medical condition. The reviewer found that as a primarily dental issue, there is no Medicare coverage. The reviewer found that treatment of the supporting structures of the teeth, eg the alveolar bone and support for the teeth or replacement teeth, are not covered services. Therefore, the reviewer found that the requested procedures do not meet medical necessity under the Medicare statute.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approvedental surgery procedures (D41899 x 4), the reconstruction of jaw (21248 x 2), the face bone graft (21210), and a lower jaw bone graft (21215).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HCPCS code K0108.
You asked the Plan to pre-approve HCPCS code K0108. You say that The Plan denied your request. The Plan says the code used for the tray and arm supports do not match the items requested. The Plan says that approval is subject to correct coding.
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 K0108 is Wheelchair component or accessory, not otherwise specified. We find that CPT code K0108 is not supported in the medical record. Specifically, HCPCS code K0108 is for use with miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code. We found that the correct code for arm rests are E0973 and K0020. We found that the correct code for an arm trough is E2209. This means that HCPCS code K0108 is
being improperly used to represent the items which have their own specific HCPCS codes. Based on this information, we decided that Medicare rules for coverage of HCPCS code K0108 have not been met. Therefore, we decided that the Plan does not have to pre-approve HCPCS code K0108.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee has not completed the full course of treatment in the hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee continues to require continued intravenous antibiotics, intravenous steroids, respiratory therapy, high-flow oxygen, and BiPAP. There is no documentation necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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.