Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 additional home health physical therapy visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says one visit can be approved.
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 the visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found you do not have documented ongoing skilled physical therapy needs. You are non-ambulatory. You have a willing and available caregiver. As such, the ongoing visits are not shown to be medically reasonable or 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 the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 17 additional home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Nitro brand rolling walker (99070).
You asked the Plan to pre-approve the Nitro brand walker. You say that the Nitro brand walker is medically
necessary. The Plan denied your request. The Plan says this specific brand walker is not supported by the
provided records.
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating
practitioner to avoid an adverse medical outcome.
We looked at the file and Medicare rules. The provided records do not detail why this specific brand of walker
is medically necessary, or why a standard walker would not meet the enrollee's needs. Based on this
information, we decided that Medicare rules for coverage of the Nitro brand walker have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Nitro brand rolling walker (99070).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to authorize an office visit with a non-participating general surgeon
You asked the Plan to authorize an office visit with a non-participating general surgeon. You say that you need to see an out-of-network surgeon for his specialty and the original decision was wrong. The Plan denied your request. The Plan says a list of in-network surgeons was provided for your request. Therefore, they could not authorize an out-of-network surgeon.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 authorize an office visit with a non-participating general surgeon. Our reviewer says that you do not meet the criteria for treatment with the requested out-of-network provider. Our physician reviewer found the record indicates that you have primary hyperparathyroidism and require surgical intervention. The record does not indicate that the Plan is unable to provide this service. The record shows that there are in-network providers available to provide the needed services. Out-of-network treatment is not medically reasonable or 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 an office visit with a non-participating general surgeon have not been met. Therefore, we decided that the Plan does not have to authorize an office visit with a non-participating general surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 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 a home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has repeated hospitalizations for acute respiratory failure secondary to congestive heart failure (CHF) and Obesity hypoventilation syndrome (OHS).  Although there is a diagnosis of chronic obstructive pulmonary disease (COPD), there are no pulmonary function tests for confirmation. It appears COPD is not the primary cause of the respiratory failure. Bilevel positive airway pressure (BiPAP) has not been tried at home. BiPAP is the appropriate treatment for OHS.  Medicare does not cover a ventilator for the treatment of OHS and does not cover a ventilator when used as BiPAP. Average volume assured pressure support (AVAPS) mode can be provided via BiPAP.  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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transportation by taxi.
You asked the Plan to pre-approve transportation by taxi. You say that you have had multiple seizures on bus
transportation. The Plan denied your request. The Plan says taxi transportation is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance.
The Plan follows the same rule.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Medicare rules for coverage of transportation by taxi have not been met. Specifically, this service is not
a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve
transportation by taxi.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided by an in-network facility from July 2, 2021, to July 20, 2021.
You asked the Plan to waive the copayments for the outpatient rehabilitation services. You say that you went to the facility and paid the copayment but refused services. You say you should not be responsible for the copayments. The Plan denied your request. The Plan says you have been asked to pay 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 $25 copayment per provider, per date of service for outpatient rehabilitation services.
You have been asked to pay a $25 copayment for the outpatient rehabilitation services on July 20, 202. You have been asked to pay an $11.71 copayment for the outpatient rehabilitation services on July 2, 2021, which is less than the standard copayment amount. The outpatient rehabilitation services fall within the "Outpatient rehabilitation services" benefit category. The medical record shows services were rendered on these dates of service. 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 copayments for outpatient rehabilitation services provided by an in-network facility from July 2, 2021, to July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast reduction procedure.
You asked the Plan to pre-approve the breast reduction procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that reduction mammaplasty will be considered medically reasonable and necessary when there are signs or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions. 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 breast reduction procedure. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the provided records do not indicate that conservative treatment has been trialed and failed. The provided record is insufficient to establish that the coverage criteria are satisfied. 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 breast reduction procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a breast reduction procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on
March 20, 2020, through April 9, 2020 and billed with Patient Driven Payment Model (PDPM) score KCGD1
x 12 days & KCGD1 x 8 days.
You asked the Plan to pay for the SNF services billed with PDPM score KCGD1 x 12 days & KCGD1 x 8
days. You say that you would like reconsideration because the documentation submitted supports the PDPM
scores billed. The Plan denied your request. The Plan says the documentation does not support the PDPM
scores billed.
The Plan follows Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a
prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment
System (HIPPS) rate code.
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 SNF services billed with PDPM score
KCGD1 x 12 days & KCGD1 x 8 days. Our reviewer says that the documentation submitted does not support
the PDPM scores billed. Our physician reviewer found the documentation does not support that the enrollee
received parenteral IV fluids during the lookback period for the 5-day assessment, and were administered
specifically for nutrition or hydration.
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 SNF services billed with PDPM score KCGD1 x 12 days & KCGD1 x 8
days have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing
Facility (SNF) services provided on March 20, 2020, through April 9, 2020 and billed with Patient Driven
Payment Model (PDPM) score KCGD1 x 12 days & KCGD1 x 8 days.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 7, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 7, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 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 care from February 7, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 7, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 7, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  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 care from February 7, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 7, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) and the handling and/or conveyance of a specimen for transfer from the office to a laboratory (99000) rendered by the out-of-network (OON) provider on February 10, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and the handling and/or conveyance of a specimen for transfer from the office to a laboratory (99000) rendered by the out-of-network (OON) provider on
February 10, 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 you would like reconsideration because the
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet
Medicare criteria for coverage of the IRF care.
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 require fifteen hours per week of rehabilitative services and 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: 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 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy, speech therapy, and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 inpatient rehabilitation facility (IRF) admission and services.
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 a CGM is medically necessary. The Plan denied your
request. The Plan says the enrollee does not meet Medicare criteria for coverage of a CGM.
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 does not indicate that the enrollee performs blood
glucose testing at least four times per day.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. You say that a trial is not indicated due to post-operative pain and recovery time. The Plan denied your request. The Plan says the member has not had a trial with spinal cord stimulator to demonstrate pain relief. In addition, there is no psychological evaluation for screening for spinal cord stimulator implantation.
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Such screening must include a psychological evaluation. Demonstration of pain relief with a temporarily implanted electrode must precede permanent implantation. The file does not show that a psychological evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. The file also does not show that the enrollee demonstrated pain relief with a temporarily implanted electrode. Therefore, we decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided by an in-
network provider on August 31, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that this doctor is a primary
care physician, and this was a surgical follow-up visit. The Plan denied your request. The Plan says you have
been asked to pay 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 $35
copayment for services furnished from an in-network specialist.
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
the provider's specialty is surgery.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the specialist office visit provided by an in-network provider
on August 31, 2021.