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

We decided that the Plan does not have to pre-approve a skilled nursing visit (G0300).
You asked the Plan to pre-approve the home health service. You say that the visit is medically necessary. The Plan denied your request. The Plan says the requested visit is 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 the home health service. Our reviewer says that additional skilled nursing visit is not medically necessary. Our physician reviewer found the records do not show that home health skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the records do not show that the enrollee requires ongoing skilled nursing services. The reviewer found that education has been provided on wound care management and the wound care is not complex in nature. Therefore, the reviewer found that the skilled nursing visit is not medically 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 home health service have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing visit (G0300).
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the required services can be safely received in a different setting.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do 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 to be 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 the admission 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: 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 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
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 an intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care (99305) provided on May 5, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the initial nursing facility care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 initial nursing facility care (99305) provided on May 5, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 7, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362, and L36523 to support their denial. However, LCD L36139, L36129, L36362, and L36523 are not valid for the provider's billing state of Pennsylvania. Therefore, we are unable to use LCD L36139, L36129, L36362, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that testing described by code 81455 (targeted genomic
sequence analysis panel for hematolymphoid neoplasm - DNA analysis of 51 or more genes) is not covered.
We looked at the file and Medicare rules. The services at issue are targeted genomic sequence analysis
described by code 81455. This testing is not covered by Medicare. Therefore, we decided that the Plan does not
have to pre-approve targeted genomic sequence analysis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armour Thyroid 90mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Armour Thyroid 90mg
tablet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are a fall risk due to your medical condition. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-covered ambulance mileage (A0888) provided on May 13, 2021.
You asked the Plan to pay for the non-covered ambulance mileage. The Plan denied your request. The Plan says that this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the Independent Review Entity (IRE) information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide an ambulance trip report or records of any kind, and do not advise what the closest appropriate facility would have been that you could have been transported to. Without records showing what your care needs were, we cannot determine whether this was the closest appropriate facility to verify that the non-covered ambulance mileage (A0888) charges are correct. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the non-covered ambulance mileage (A0888) provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided December 2, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the tests were 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 pay for the lab services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found there was no initial urine drug screening. The provider also did not document any individualized patient concerns about risks in failing to identify non-prescribed medication or illicit substances to be able to safely prescribe controlled substances. 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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Urolift procedure. 
 
You asked the Plan to pre-approve Urolift. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is 
doing well on his current medication. 
 
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 Urolift. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records indicate that the enrollee is being effectively managed with medication and not 
experiencing side effects. In this case, Urolift would be considered mainly for the convenience of the patient or 
the physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Urolift have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Urolift procedure.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the patient was admitted for pneumonia, mental status changes, and a hip
fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The
patient 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 an intensive, multi-disciplinary
rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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 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 power wheelchair and battery.
You asked the Plan to pre-approve a power wheelchair and battery. You say that you need a wheelchair to get around and you cannot walk. The Plan denied your request. The Plan says the requested item is a duplicate to an item you currently have.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a current power wheelchair. The documentation shows that you received this power wheelchair on May 10, 2021. Your current power wheelchair serves the same purpose as the requested power wheelchair and battery. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and battery.
Appeal type: Transportation
Decision: Unfavorable

we decided that the Plan does not have to waive the copayment for the non-emergent wheelchair van transportation services (A0130), S0209) provided on June 15, 2021.
You asked the Plan to waive the copayment for the wheelchair van services. You say that it was necessary for you to be transferred from one facility to the other, and you were told your insurance would cover this transportation. The Plan denied your request. The Plan says there is a $125 copayment for each one-way ambulance transportation trip. The total cost of services is less than the required copayment, so you are responsible for the full allowed cost.
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. The rules say that Medicare does not pay for wheelchair van transport services. You have asked the Plan to waive the copayment for are wheelchair van transport services. Wheelchair van transportation is not a service that is covered by Medicare or by the Plan. The Plan has chosen to process the wheelchair van transportation as a covered service and apply the $125 ambulance copayment. The allowed amount for this service is less than the required copayment for ambulance care, and this cost is your responsibility. We cannot review cost-sharing for services that are not covered. Therefore, we decided that the Plan does not have to waive the copayment for the non-emergent wheelchair van transportation services (A0130), S0209) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on January 22, 2021.
You asked the Plan to pay for the extraction (D7140). You say that you sent a request but did not get a refund. You say that you have supplemental benefits and don't understand why you can't be reimbursed for part of the cost. The Plan denied your request. The Plan says the service is 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 pay for the extraction (D7140) provided on January 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the noncovered ambulance mileage (A0888) provided on March 7, 2021.
You asked the Plan to pay for noncovered ambulance mileage. You say that it was medically necessary to go to this other facility, because the enrollee did go to the closer hospital a few weeks earlier but experienced worsening symptoms after that visit. The Plan denied your request. The Plan says documentation shows that you chose to go to this facility rather than the closer one out of personal preference. A waiver was signed indicating that you understood you would likely be responsible for this additional mileage. This request cannot be approved.
Medicare pays for local ambulance services and will only cover mileage to the nearest appropriate facility equipped to treat the patient. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance mileage have not been met. Specifically, the closest available facility to treat the enrollee was approximately a mile away from the enrollee's home. The chosen destination facility is over 40
miles away by the fastest route according to google maps. There is no indication that the closer facility would not have been able to provide the necessary emergency care. The record shows that you chose this hospital out of preference and were notified that you may be responsible for the extra mileage costs. Therefore, we decided that the Plan does not have to pay for the noncovered ambulance mileage (A0888) provided on March 7, 2021.