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

We decided that the Plan does not have to pre-approve the three additional skilled nursing visits.
You asked the Plan to pre-approve the additional skilled nursing visits. The Plan denied your request. The Plan says the medical records submitted on your behalf do not indicate that you need a skilled nurse to change your dressings, or that your wounds have gotten worse.
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 additional skilled nursing visits. Our reviewer says that the frequency of requested skilled nursing visits is not shown to be medically necessary and reasonable. Our physician reviewer found you have an ileal conduit/nephrostomy. There is no evidence of related complications. Our reviewer found that you are noted to manage flushing and monitoring of the device. Our physician reviewer also found that while periodic skilled observation is reasonable, frequent skilled monitoring is not 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 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the three additional skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a family practitioner on February 26, 2021.

You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical and should have no copayment, even if you have questions about a medical condition. 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 $10 copayment for visits with a primary care provider. 

The medical records from this visit show that you were scheduled for an annual wellness visit. However, the records show that in addition to the annual wellness visit, you were evaluated for hypertension, palpitations, chest congestion, and to discuss immunizations. You have been asked to pay a $10 copayment for the office visit. According to your Evidence of Coverage, if medical conditions are addressed during an annual wellness visit or physical, a separate copayment applies for that. That is why you were charged the $10 copayment for a primary care visit. 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 office visit you had with a family practitioner on February 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health counseling to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the outpatient services. You say that you would like to appeal for not being able to see this provider. This was indicated by the court that you have to see this provider. You sent the paperwork from the court showing that you need to see him. The Plan denied your request. The Plan says the provider is a licensed mental health counselor and is not a qualified provider. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient mental health counseling to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulation therapy, vasopneumatic device therapy, and subcutaneous injection services.

You asked the Plan to pre-approve electrical stimulation therapy, vasopneumatic device therapy, and subcutaneous injection services. You say that you have chronic pain that is affecting your quality of life. You say that the requested services would increase your quality of life and help you return to your previous levels of function and comfort. The Plan denied your request. The Plan says the denial of the requested services was appropriate given the clinical scenario presented in the records provided.

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 electrical stimulation therapy, vasopneumatic device therapy, and subcutaneous injection services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these therapies have not been shown to be efficacious in scientific trials.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrical stimulation therapy, vasopneumatic device therapy, and subcutaneous injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical stimulation therapy, vasopneumatic device therapy, and subcutaneous injection services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary.
The Plan denied your request. The Plan says rules for SNF care have not been met.
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 you are a 70-year-old male long-term care
facility resident with a past medical history of hypertension, bipolar disorder and progressive paraplegia related
to cervical spinal stenosis. You were admitted to an acute hospital on June 16, 2021, for a cervical spine
laminectomy/fusion and revision of hardware. While you do require skilled therapy services, based on the
medical records provided there is no documentation that you require skilled nursing services. In addition, daily
skilled services are not required. Based on the medical records provided this patient did not require the services
on an inpatient basis, only 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 admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on June 15, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you feel that the MRI should have been done during a previous hospital stay. 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 $175 copayment for MRI's. You have been asked to pay a $175 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an MRI provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stage II bariatric surgery for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show evaluation from a bariatric surgeon, primary care physician, or
mental health professional.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has morbid obesity. The provided records do mot document
involvement of a bariatric surgery team that has performed an evaluation as required by the criteria.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve stage II bariatric surgery for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the individual therapy visit you had at an outpatient hospital facility on May 14, 2021.
You asked the Plan to waive the copayment for the individual therapy visit. You say that the facility billed you $55 even though this was not a partial hospitalization like it was coded. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this claim was not billed as a partial hospitalization, but as outpatient mental health care performed in an outpatient facility setting. The copayment is not limited to partial hospitalizations.
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 $55 copayment for mental health care at an outpatient hospital facility.
You have been asked to pay a $55 copayment for the individual therapy visit. The individual therapy visit falls within the mental health care at an outpatient hospital facility 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 individual therapy visit you had at an outpatient hospital facility on May 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional skilled physical therapy (PT) visits
(G0151).
You asked the Plan to pre-approve 6 additional skilled PT visits. You say that the requested services are
medically necessary. The Plan denied your request. The Plan says the additional 6 physical therapy visits are
not medically necessary.
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 6 additional skilled PT visits. Our
reviewer says that the additional skilled PT visits are not medically necessary. Our physician reviewer found
the provided medical records do not indicate 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 for the 6 denied
physical therapy visits at issue in this case. The reviewer found that the documentation provided shows that the
enrollee has had extensive physical therapy since 2018 with no recent change in condition or level of function.
Therefore, the reviewer found that the additional 6 PT visits are 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 6 additional skilled PT visits have not been met. Specifically, the file shows that
there has been no recent change in condition or level of function with previous physical therapy. Therefore, we
decided that the Plan does not have to pre-approve 6 additional skilled physical therapy (PT) visits (G0151).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve angioplasty and stent placement.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that medical need has 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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. You have no signs or
symptoms suggestive of limb threat with ankle brachial index (ABI) of 0.85 on the right and 0.89 on the left.
Despite your history of peripheral arterial disease (PAD), you apparently have undergone ablation of both
greater saphenous veins. You have numerous other etiologies that limit your walking distance including recent
pulmonary embolism, shortness of breath with exertion, arthritis, chronic back pain, and hip and knee pain, that
according to your vascular provider, limit your mobility. As you currently do not have any evidence of limb
threat, and, based on the current documentation, you have multiple limiters to your mobility that would not
change with arterial intervention, there is insufficient information to support medical necessity in the medical
record. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve angioplasty and stent placement.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
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. In this case, the services were billed with POS code 15. This code does not reflect the setting in which the enrollee received the face-to-face service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on February 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from March 6, 2021 to April 4, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed in 60 day episodes.
We looked at the file and Medicare rules. The file shows that the claims were not billed in 60 day episodes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from March 6, 2021 to April 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there are not enough studies on the Vertiflex device to show it is safe and effective.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.

You asked the Plan to pre-approve 6 additional physical therapy visits. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 6 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have had extensive therapy for this condition and have been approved for additional therapy for instruction in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture.
You asked the Plan to pre-approve the mandibular partial denture. You say that you have a full upper denture and a partial lower denture that has spaces and teeth that are missing. You say that it is very hard for you to process food. The Plan denied your request. The Plan says dentures are 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 a mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on April 7, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the charges because you have had the device for over 20 years and should not need to have another script sent in. 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 10% coinsurance for DME and related supplies. You received DME and related supplies on April 7, 2021. Therefore, you are responsible to pay your share of
the cost-sharing charges. The total allowed amount is $357 and 10% of that is $35.70. You have been asked to pay the total coinsurance amount of $35.70 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies provided on April 7, 2021.