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

We decided that the Plan does not have to pre-approve auricular peripheral nervous system (PNS) device.
You asked the Plan to pre-approve auricular PNS device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 auricular PNS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic bilateral leg and foot pain accompanied by lymphedema. The enrollee has tried Physical Therapy and Gabapentin. The requested therapy is unproven and experimental. Therefore, the enrollee does not meet criteria for the requested 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 auricular PNS device have not been met. Therefore, we decided that the Plan does not have to pre-approve auricular peripheral nervous system (PNS) device
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The
Plan denied your request. The Plan says a SNF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral and inhaled medications and insulin. The enrollee had stable vital signs.
He used oxygen via nasal cannula. He had uncomplicated wound care to his sacral and scrotal wounds.
Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational
therapy. The enrollee was at a supervision to contact guard/minimal assist level with functional mobility. The
enrollee required varying assist with activities of daily living. He tolerated a mechanical soft diet and thin
liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service
needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter,
this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of sclerosant multiple incompetent veins other than telangiectasia same leg (CPT code 36471).
You asked the Plan to pre-approve the service. You say that you are unable to walk or even leave the house without your knees being wrapped. You state that you are so much pain and have so much pain it is beginning to affect your daily duties. The Plan denied your request. The Plan says this request is not medically necessary because the veins to be treated are less than 4 mm in diameter and there is no documentation supporting the absence of or prior treatment of saphenous vein reflux.
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 service. Our physician reviewer found the record does not indicate that the veins to be treated are greater than 4mm. The records provided do not contain primary source documentation of conservative treatment attempts. The elements of the coverage determination are not satisfied. The requested service cannot be 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection of sclerosant multiple incompetent veins other than telangiectasia same leg (CPT code 36471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554).
You asked the Plan to pre-approve a CGM receiver. You say that the item is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
CGM receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a
continuous glucose monitor (CGM) receiver (K0554).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on June 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you are the only facility capable of the testing which the physician requested. You say the service is clearly 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. The record shows the enrollee was referred by an out-of-network physician. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 7, 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 wound care treatment to be provided by an OON
provider.

You asked the Plan to pre-approve wound care. You say that you do not understand how your needs can be met
within the Plan network if you are in Florida, and this wound care coverage is urgent. The Plan denied your
request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network
with the plan and you can be treated by an in-network wound care specialist.

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
wound care treatment to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your
request. The Plan says you are not on insulin three times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor (CGM).
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hamstring releases surgery to treat limb contracture and was discharged home with home health services. Medical problems are stable. 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. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following the elective left total hip arthroplasty (CPT code 27130), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 acute inpatient hospital care. 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 the enrollee will require inpatient services that will likely cross 2 midnights for this lower risk ambulatory procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care following the elective left total hip arthroplasty (CPT code 27130), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the molecular pathology procedure
provided on February 10, 2021.
You asked the Plan to waive the coinsurance for the molecular pathology procedure. You say that this is the
most comprehensive liquid biopsy panel which was deemed medically necessary for the member. You say that
there was not an in-network provider that could offer comparable testing and the claim should be processed
against the in-network benefits. The Plan denied your request. The Plan says the coinsurance applied 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance is for molecular or predisposition genetic testing.
The enrollee has been asked to pay $700, which is 20% of the allowed amount for the molecular pathology
procedure. The allowed amount is $3,500 (20% x $3,500 = $700). The molecular pathology procedure falls
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records
show the molecular pathology procedure was processed toward the in-network benefit. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for the molecular pathology procedure provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laboratory work to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the laboratory work. You say that the provider had been in-network when you signed up for the Plan and it is not your fault the provider's network status changed. The Plan denied your request. The Plan says the provider is out-of-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 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 laboratory work to be provided 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 the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 at the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation (PMR) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No documented skilled nursing needs. Documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least five (5) days per week with frequent physician oversight and an
interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of current medical complexity and lack of skilled nursing needs. While the enrollee may benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's therapy needs can be addressed at a lower intensity level such as in a skilled nursing facility (SNF) setting. 

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 IRF admission and services.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and chronic obstructive pulmonary disease (COPD) exacerbation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a tendon sheath incision provided on May 17, 2021.

You asked the Plan to waive the copayment for a tendon sheath incision. You say that you used to work at this hospital and thought there would be a discount. You state that the charges are too high and you cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received a tendon sheath incision on May 17, 2021, at an outpatient hospital facility. A tendon sheath incision is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $400 copayment.

You have been asked to pay a $400 copayment for a tendon sheath incision. A tendon sheath incision falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a tendon sheath incision provided on May 17, 2021.