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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical necessity guidelines were not met for this admission.
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
congestive heart failure. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging, any joint of upper extremity (73221) provided on March 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that the billed outpatient imaging was medically necessary and reasonable, based on the need for outpatient diagnosis and treatment. You ask for reconsideration for approval for procedure code 73222 and subsequent payment. The Plan denied your request. The Plan says services was provided beyond the effective date of the prior authorization. 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging, any joint of upper extremity (73221) provided on March 26, 2021 by an out-of-network (OON) provider.
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 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 the enrollee is an 82-year-old male nursing
home resident with a past medical history of anemia, urinary retention, chronic kidney disease and pulmonary
hypertension who presented to the acute hospital on September 5, 2021, with urosepsis. While there are skilled
physical therapy service needs, there are no skilled nursing service needs. In addition, these skilled services are
not required on a daily basis. Based on the medical records provided this patient does not require the services
on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part
time basis appear appropriate in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the driving evaluation.

You asked the Plan to pre-approve the driving evaluation. You say that you need the occupational therapy to
return to work. You say that you have not had issues with approval of therapy in the past and this is impacting
your ability to continue working. The Plan denied your request. The Plan says Medicare does not cover
screening and routine physical examinations to check the ability to drive.

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if
regular Medicare would pay for it.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the driving evaluation have not been met. Specifically, driving evaluations are not a covered
benefit under Medicare. Therefore, we decided that the Plan does not have to pre-approve the driving
evaluation.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 15, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you have no knowledge of patient coverage 
prior to the specimen's arrival at the laboratory. You also say that you should not penalize the laboratory for 
being out of network as you continue to do your part in providing timely testing and results to the coronavirus 
pandemic. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the
enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a problem focused limited oral evaluation (D0140) and
extraction (D7140) to be rendered by an OON provider.

You asked the Plan to pre-approve the problem focused limited oral evaluation and extraction. You say that
you were referred by your dentist to see this OON oral surgeon. You also say that the Plan does not have any
in-network oral surgeons within 60 miles of where you live. The Plan denied your request. The Plan says
services provided by an OON or non-contracted provider are not covered under this benefit program. The Plan
also says that there are in-network providers available who can supply the requested services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a
problem focused limited oral evaluation (D0140) and extraction (D7140) to be rendered by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of intravenous moderate sedation (D9239) and an additional 15 minutes of intravenous moderate sedation (D9243).

You asked the Plan to pre-approve the dental services. You say that you have high blood pressure. You say that the surgery is extensive, and you cannot do procedure without sedation. You also say that you do not have money for these services. The Plan denied your request. The Plan says anesthesia services are excluded from coverage.

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 dental anesthesia are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of intravenous moderate sedation (D9239) and an additional 15 minutes of intravenous moderate sedation (D9243).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a ventricular assist device (33990).
You asked the Plan to pre-approve the implantation of a ventricular assist device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a ventricular assist device is indicated for post-cardiotomy or FDA approved left ventricular assist devices that meet the criteria listed in the National Coverage Determination. 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 implantation of a ventricular assist device. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found in this case, the enrollee is undergoing an ablation procedure. The requested device is not being used for a condition enumerated in the coverage criteria. The enrollee is not in a investigation device exemption study or coverage with evidence development study. 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 implantation of a ventricular assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a ventricular assist device (33990).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) and wheelchair van mileage (S0209) provided on April 19, 2021.
You asked the Plan to pay for the wheelchair van and wheelchair van mileage. You say that you say that this trip was Coronavirus related and you feel that the copayment should be waived. The Plan denied your request. The Plan says a physician's office is not a covered destination for wheelchair services.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. The record does not show that the non-ambulance transportation was provided from a hospital to an SNF. Therefore, we decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) and wheelchair van mileage (S0209) provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided on March 22, 2021.

You asked the Plan to pay for the diabetic testing supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items billed are not supported by the documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that the documentation does not contain documentation including the enrollee's diagnosis and other pertinent information including, but not limited to, duration of the enrollee's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve 20 additional non-emergency transportation trips. You say that the number 
of transportation trips is not enough for your doctor visits and you need 20 more trips for future visits. The Plan 
denied your request. The Plan says you receive 42 one-way non-emergency trips per year. The Plan also says 
that you have 19 single trips left until your benefit is exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers 42 one-way taxi or van trips to plan-approved locations every year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for additional coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 20 additional non-emergency transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
left knee arthroscopy and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 enrollee is approved for a left knee arthroscopy. The record do es not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health counseling and therapy (H0004) and 
medication training and support (H0034) provided on October 8, 2020, through February 12, 2021. 
 
You asked the Plan to pay for the behavioral health counseling and medication training and support. You say 
that you would like reconsideration because this Plan is the member's primary insurance. The Plan denied your 
request. The Plan says CPT codes H0004 and H0034 have a status indicator of I and are not valid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes H0004 and H0034 are not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT codes H0004 and H0034 have a status indicator of I. This means that CPT codes H0004 and 
H0034 are not valid for Medicare purposes. 

Based on this information, we decided that Medicare rules for coverage of the behavioral health counseling and 
medication training and support have not been met. Therefore, we decided that the Plan does not have to pay 
for behavioral health counseling and therapy (H0004) and medication training and support (H0034) provided 
on October 8, 2020, through February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing.
You asked the Plan to pre-approve BRCA 1 and BRCA 2 testing. You say that you have a huge history of cancer in your family. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 testing are only covered for certain indications. 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 BRCA 1 and BRCA 2 testing. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have a history of hypertension and vulvar cancer. The documentation does not support that you or a family member has had a diagnosis of breast, ovarian, prostate, or pancreatic cancer. Therefore, you do 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 BRCA 1 and BRCA 2 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the dental item. You say that after you had radiation treatments, you received light therapy to try and save your teeth. You say that your dentist advised you would have issues with your teeth in the future. You also say that your teeth are now affecting you. The Plan denied your request. The Plan says dentures are not a covered service.
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 denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
You asked the Plan to pre-approve hearing aids. You say that you can get a similar pair of hearing aids at this provider for $1,800. You say that you want to purchase these hearing aids and get reimbursed $500. The Plan denied your request. The Plan says in-network providers are 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 hearing aids from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for nebulizer, with compressor (E0570) provided April 29, 2021.

You asked the Plan to pay for the nebulizer. You say that you purchased the nebulizer because you needed it right away in order to follow up with the additional breathing treatments and home and to avoid a hospital visit and/or stay. You are asking for reconsideration for payment. The Plan denied your request. The Plan says the plan will only cover the rental of nebulizers from approved suppliers and will not cover the cost of purchasing one.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Per Medicare, this item is considered a capped rental item, meaning it must first be rented and cannot be purchased. Based on this information, we decided that Medicare rules for coverage of the nebulizer have not been met. Therefore, we decided that the Plan does not have to pay for nebulizer, with compressor (E0570) provided April 29, 2021.