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

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 admission to a long-term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an OON provider.
You asked the Plan to pre-approve specialist services. You say that you would like to see this specific provider.
The Plan denied your request. The Plan says there are in-network specialist available to provide 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 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
specialist services to be provided by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7471).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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, 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 dental services (D7471).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), periodontal maintenance (D4910), and preventive procedure (D1999) provided on February 11, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the periodic oral evaluation, periodontal maintenance, and preventive procedure. You say that you were not advised that the treating provider had opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective July 1, 2016, to July 1, 2022.
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, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation (D0120), periodontal maintenance (D4910), and preventive procedure (D1999) provided on February 11, 2021 by a Medicare opt out provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional services of an HHA (G0156).
You asked the Plan to pre-approve the additional services of an HHA. You say that you need 14 hours of HHA services per week. The Plan denied your request. The Plan says the HHA services at request are not supporting a skilled need being taken care of by a nurse but are custodial in nature.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the additional services of a HHA. Our
reviewer says that the additional HHA services are not shown to be medically necessary or reasonable. Our
physician reviewer found the HHA services being provided do not appear to be part of a treatment program to
treat an illness or injury. Our reviewer also found that the HHA services being provided appear to be custodial
and service related.
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 additional services of a HHA have not been met. Therefore, we decided that
the Plan does not have to pre-approve the additional services of an HHA (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient hospital admission.
You asked the Plan to pre-approve the inpatient hospital admission. You say that you are getting knee surgery and your doctor recommends and inpatient stay overnight after the surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the documentation does not support that it is reasonable for the admitting physician to expect that your necessary hospital care will span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and the pneumatic compression appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that please review the attached prior authorization form with the enrollee, provider and product details. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
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-approve a pneumatic compression device (E0652) and the pneumatic compression appliance (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy to regain maximum
functioning ability and strength. The Plan denied your request. The Plan says that the enrollee can safely
receive the services needed, in other settings.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke with left
sided weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation
needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. 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. 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. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260).

You asked the Plan to pre-approve osseous surgery (D4260). The Plan denied your request. The Plan says the service is not a covered benefit.

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, 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 osseous surgery (D4260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator.
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan
denied your request. The Plan says a BiPaP could be used alternatively to the 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 the home ventilator. Our reviewer says
that the service is not medically necessary. Our physician reviewer found the ordering physician has not
demonstrated that the BiPAP machine with AVAPS settings is not appropriate for the enrollee in this case.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home mechanical ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of deep sedation/general anesthesia
(D9222) and two subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x2).
You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that you need to have three of
your teeth surgically removed because they are infected. The Plan denied your request. The Plan says these
services are not covered under your plan. The Plan also says that you do not have any separate dental rider with
the Plan.
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, 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 the
first 15 minutes of deep sedation/general anesthesia (D9222) and two subsequent 15 minute increments of deep
sedation/general anesthesia (D9223 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
March 16, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The 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 out of network physician services provided to the enrollee on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show an evaluation by a surgeon.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this request is experimental. More research is needed to show safety and efficacy of the 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 the surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve spinal fusion surgery for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound you had on April 23, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you cannot afford this copayment. 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 $125 copayment for radiological diagnostic services, including ultrasounds. 

You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic services 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 for the retroperitoneal ultrasound you had on April 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on May 3, 2021.

You asked the Plan to waive the copayment for the ECG. You say that you do not understand why the Plan isn't paying anything for this test. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the ECG ($15.37) is less than your copayment obligation, you are responsible for the full allowed amount for this service.

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 $20 copayment for non-radiological diagnostic services. 

You have been asked to pay a $20 copayment for the ECG. The ECG falls within the non-radiological diagnostic services 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 for the electrocardiogram (ECG) you had on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.

You asked the Plan to pre-approve a lightweight wheelchair. You say that you feel this item is medically necessary. The Plan denied your request. The Plan says the requested lightweight wheelchair is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that lightweight wheelchairs are only covered when both 1 and 2 criteria are met:

1. Cannot self-propel in a standard wheelchair in the home; and 
2. The beneficiary can and does self-propel in a lightweight wheelchair 

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 lightweight wheelchair. Our reviewer says that the documentation does not support that the requested lightweight wheelchair is medically reasonable or necessary. Based on the medical records provided you do not meet Medicare criteria for coverage of the lightweight wheelchair as there is no documentation that you cannot self-propel in a standard wheelchair in the home and you can and do self-propel in a lightweight wheelchair. Our physician reviewer found you recently suffered a right tibia fracture.

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 lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (CPT code 99292) provided to the enrollee on April 5, 2020.
You asked the Plan to pay for the services. You say that this enrollee was in the intensive care unit (ICU) and under critical care treatment for this date of service. You state the hospital cannot get a physician to come in and cover the overnight shift in the ICU s they contracted the telehealth provider to render the service. The Plan denied your request. The Plan says that the claim was upheld due to no correction made to provider's address.
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. It appears that the plan's contracted delegate failed to forward documentation to support the decision to deny based on an incorrect provider address. Therefore, we decided that the Plan has to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (CPT code 99292) provided to the enrollee on April 5, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs (E2374, K0108).
You asked the Plan to pre-approve the power wheelchair repairs. You say that the repairs are medically necessary. The Plan denied your request. The Plan says a new power wheelchair was already approved. A new chair is more cost effective and meets the enrollee's needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the plan has already approved a new power wheelchair. The new wheelchair serves the same purpose as the repaired one would serve. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs (E2374, K0108).