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

We decided that the Plan does not have to pre-approve a spinal surgery.
You asked the Plan to pre-approve a spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interlaminar stabilization devices are experimental. More research is needed to show safety and efficacy. 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal surgery
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0012) and accessory (E2321).
You asked the Plan to pre-approve a power wheelchair and accessory. You say that you are at risk for falls. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for a power wheelchair to be covered, the supplier or practitioner must perform an on-site evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device. We looked at the file and Medicare rules. The submitted records do not show that you have had a home evaluation. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0012) and accessory (E2321).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from August 17, 2020, through August 27, 2020, billed with secondary diagnosis codes J96.21 and J96.22.
You asked the Plan to pay for the inpatient services as billed. You say that it is felt that at least J96.22 is supported as elevated carbon dioxide levels are documented throughout the admission. The Plan denied your request. The Plan says there are none of the other clinical signs/symptoms of acute respiratory failure to support including this as a secondary diagnosis for this admission.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis codes J96.21 (Acute and chronic respiratory failure with hypoxia) and J96.22 (Acute and chronic respiratory failure with hypercapnia). 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 the inpatient services as billed. Our reviewer says that the two reported secondary diagnosis codes are not supported by the records. Our physician reviewer found even though Acute and chronic respiratory failure with hypoxia and hypercapnia was documented as a diagnosis on progress notes and discharge summary, supporting medical record documentation was not found within the record. The enrollee had shortness of breath, but a baseline oxygen and carbon dioxide level were not documented. The enrollee also received 4 liters per minute of oxygen which is noted as at baseline. There was some documentation of elevated carbon dioxide, but pH was normal. There was no documentation of a respiratory rate over 30, use of accessory muscles, or any change in mental status due to hypoxia. The review has determined that the use of diagnosis code J96.21 is not supported by the records provided. The use of diagnosis code J96.22 is not supported by the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from August 17, 2020, through August 27, 2020, billed with secondary diagnosis codes J96.21 and J96.22.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pacemaker evaluation provided on August 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the pacemaker evaluation. You say that the enrollee was unable to seek the correct primary care physician to sign their orders, and the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 pacemaker evaluation provided on August 23, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on August 10, 2021, and August 11, 2021.
You asked the Plan to pay for the self-administered drugs. You say that these drugs should be covered as part of your plan with drug coverage. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare.
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 pay for the self-administered drugs provided on August 10, 2021, and August 11, 2021.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on December 22, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON)
provider on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home mechanical ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied
your request. The Plan says that the request for a home mechanical ventilator set in intelligent volume average
pressure support (IVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not
covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan has not substantiated their denial in this case. The plan's narrative
makes it clear that they had access to clinical information and medical records to make their decision. There
were no medical records provided for review in this case. Therefore, we decided that the Plan has to preapprove
a home mechanical ventilator.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 home health physical therapy.
You asked the Plan to pre-approve 9 home health physical therapy. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 9 home health physical therapy. Our
reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates
that the records did not show that skilled nursing services are required to effectively provide treatment, care,
and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to
maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's
level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function
and/or prevent deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 9 home health physical therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve 9 home health physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to neurology.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 an out-of-network referral to neurology
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a queen size adjustable bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says a queen size adjustable bed is not listed as a covered bed under Medicare guidelines.
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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a queen size adjustable bed for the enrollee.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care such as a skilled nursing facility. 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 pay for the office visit provided on March 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this service did not require authorization. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided on March 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation for autologous stem cell transplant.
You asked the Plan to pre-approve an evaluation for autologous stem cell transplant. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 an evaluation for autologous stem cell transplant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an evaluation for autologous stem cell transplant have not been met. Therefore, we decided that the Plan does not have to pre-approve an evaluation for autologous stem cell transplant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the eye exam and fundus photography provided on March 19, 2021.
You asked the Plan to waive the deductible for the eye exam and fundus photography. You say that you were not aware of the benefit for a routine eye exam being provided by the medical plan. You say that there should have been no cost. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 deductible which applies to a medical eye exam and diagnostic tests. The item or service you asked the Plan to waive the deductible for fall within the "Vision Care" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to a medical eye exam and diagnostic tests.
This cost sharing is a contractual obligation that had not been met at the time the eye exam and fundus photography were received on March 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the eye exam and fundus photography provided on March 19, 2021.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician
evaluation. 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-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 20, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were at a restaurant and experienced a vasovagal attack and the restaurant called the ambulance. You say that you have worked with your doctor regarding this condition, and you know that once you come to and are coherent then there is no further medical attention needed. You say that the health Plan should pay for this service because you saved the insurance a lot of money by not going to the hospital for all kinds of unnecessary testing. The Plan denied your request. The Plan says payment is not provided for ambulance response and treatment at the scene without transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar sacral facet joint blocks.
You asked the Plan to pre-approve lumbar sacral facet joint blocks. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 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 lumbar sacral facet joint blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar sacral facet joint blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar sacral facet joint blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 27, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were experiencing excruciating pain and this procedure was necessary. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 1, 2021 and your problem focused limited oral evaluation
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 27, 2021