Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a percutaneous laminectomy with image guidance for enrollee.You asked the Plan to pre-approve these services.You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that percutaneous laminectomy is covered when specific criteria are met. 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 medically necessary. Our physician reviewer found the enrollee has persistent low back pain radiating into the bilateral lower extremities. Signs/symptoms are reported consistent with neurogenic claudication. Symptoms interfere with quality of life and activities of daily living. Clinical exam findings do not evidence a focal neurologic deficit. There is imaging evidence of moderate central canal stenosis secondary to ligamentum flavum hypertrophy at the L3/4 level, and severe central canal stenosis with ligamentum flavum hypertrophy at the L4/5 level. She has failed to improve despite conservative treatment including activity modification, NSAIDs, physical therapy, and epidural steroid injection. The records show that the enrollee meets the criteria for coverage and is participating in the CED Longitudinal Study. The requested procedure is therefore reasonable and 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 been met.Therefore, we decided that the Plan has to pre-approve a percutaneous laminectomy with image guidance for enrollee. 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: 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-approveSNF services. You say that you will benefit from short-term rehabilitation.The Plan denied your request. The Plan says that your rehab and medical needs can be met at a lower level of care with skilled intermittent therapy and nursing in a community setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine 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-approveskilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You say that because of your medical condition the height adjustment feature is not a convenience but a necessity.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 hospital services. Our physician reviewer found this enrollee did appear to require inpatient mental health treatment as although he was not a danger to himself or others and was cooperative and compliant he was having auditory hallucinations. It did appear that active treatment was taking place. It did appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does meet the criteria for acute inpatient mental health treatment as although this patient was not shown to be a danger to himself or others and was without agitation or aggression, he did have perceptual disturbance including auditory hallucinations. 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 hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient mental health care, for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and the debridement of subcutaneous tissue provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for the wound care services. You say that authorization was obtained before the services were provided to the enrollee. You say that authorization should have been obtained by the enrollee's referring physician. You also say that the provider rendered the services to the enrollee in good faith.The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the services were not urgent or emergent. The Plan also says the services could be 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.Although the enrollee's plan has a Point of Service (POS) benefit, authorization is still required to see any out of network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan 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 subsequent nursing facility care and the debridement of subcutaneous tissue provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmented appliance sleeve (E0667).You asked the Plan to pre-approvea pneumatic compression device. You say that you are requesting an appeal regarding denial of coverage.The Plandenied your request. The Plan says the enrollee does not meet the criteria as the enrollee has not had a four week trial of the E0650 or E0651. Therefore, E0667 is non-covered when requested in conjunction with the non-approved code E0652.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmented appliance sleeve (E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 29, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for an office visit provided on July 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on March 28, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on March 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that the requested LTACH care is medically necessary.The Plandenied your request. The PlansaysLTACH care would not be clinically superior to simply remaining in the current facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for endocarditis and renal failure. The enrollee is receiving a prolonged course of antibiotics and has been started on hemodialysis. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care forany ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 17, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that it takes a half hour to set up the machine and the profusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography with Doppler provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician service. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the service. The Plan also says the service 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 requested 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 echocardiography with Doppler provided on September 11, 2019 by an out of network (OON) provider.
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 you want to have more mobility and to walk again. The Plan denied your request. The Plan says you do not require intensive complex interdisciplinary therapy for the treatment of an acute event.
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 physician reviewer found that you are independent with bed mobility, moderately independent with transfers, and dependent with ambulation. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status required the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional physical and occupational therapy, but you do not require this on an intensive rehabilitation facility therapy program level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe observation stay provided from November 2, 2019 to November 3, 2019.You asked the Plan to reduce the copayment forthe observation stay. You say that you should only pay the emergency room copayment because you went straight in. You say you do not want to pay the observation copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $250 copayment for observation services. You have been asked to pay a $250 copayment for the observation stay. The observation stay falls within the"Outpatient hospital services" benefit category. The medical record shows you were admitted into observation.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 reduce the copayment forthe observation stay provided from November 2, 2019 to November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert necklace.
You asked the Plan to pre-approve an alert/alarm device. You say that you fall often so you need a Life Alert for your safety. The Plan denied your request. The Plan says alert/alarm devices are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare does not cover alert/alarm devices. Therefore, we decided that the Plan does not have to pre-approve a Life Alert necklace.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from September 7, 2019 at 10:51am through September 8, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,approval is required. 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 inpatient hospital care. Our physician reviewer found the review has determined that the post-stabilization care services September 7, 2019 at 10:51am through September 8, 2019 were not medically necessary and reasonable. The member was hemodynamically stable for ambulance transport with monitoring and oxygen to a Plan facility. There was no documentation provided necessitating post-stabilization care services at a non-participating Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was notstable for transfer on any dates of service.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 hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from September 7, 2019  at 10:51am through September 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral sleep apnea appliance to be provided by an out of network provider, 
You asked the Plan to pre-approve the sleep appliance. You say that there is no dentist in-network within 40 miles that is a DME supplier and a dentist. The Plan denied your request. The Plan says there are 3 in-network providers within a 30-mile radius of your zip code.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the oral sleep apnea appliance to be provided by an out of network provider,
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to on March 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 the claim was 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 claim for these services was billed with POS code 81 for an independent laboratory; 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 drug testing rendered to on March 25, 2019.