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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that that you would like to continue therapy at the SNF so you can return to your prior level of functioning. The Plan denied your request. The Plan says that a lower level is more appropriate for you.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dialysis services to be performed by out-of-network
providers.
You asked the Plan to pre-approve the dialysis services. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says there are in-network providers that can render the
services.
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 dialysis services to be performed by out-of-network providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the request for a home mechanical ventilator set in average volume assured pressure
support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.
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 the DME. Our physician reviewer
found the record indicates that you have chronic respiratory failure from chronic obstructive pulmonary
disease. The provided primary source documentation does not contain sufficient detailed information in the
medical record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS
capability. The Plan has indicated such a device is covered. The elements of the coverage criteria are not
satisfied. The requested service cannot be recommended
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve the home ventilator (CPT code E0466).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Sandostatin.

You asked the Plan to pre-approve Sandostatin. The Plan denied your request. The Plan says that Sandostatin for the treatment of gastric antral vascular ectasia is not FDA-approved.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Sandostatin. Our physician reviewer found that the enrollee has gastric ectasia. The requested use of Sandostatin is not FDA-approved for the enrollee's diagnosis. However, it is supported by clinical research that appears in a CMS-approved medical journal, the World Journal of Gastrointestinal Endoscopy. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Therefore, the documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sandostatin have been met. Therefore, we decided that the Plan has to pre-approve Sandostatin.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services.
You asked the Plan to pre-approve the routine transportation services. The Plan denied your request. The Plan
says the requested transportation services exceed the benefit mileage limitation.
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 routine transportation when each one-way trip does not exceed 50 miles.
We looked at your request, the records in the case file, and the rules. The case shows that the location you are
requesting routine transportation to is more than 50 miles from your home address. Based on this information,
we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we
decided that the Plan does not have to pre-approve routine transportation services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from October 6, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee is still inpatient. The Plan denied your request. The Plan says the stay is 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 mental health care. Our physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 6, 2021, forward and could have been treated in a lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from October 6, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on May 19, 2021.

You asked the Plan to pay for the preventive procedure. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered.

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 preventive procedure (D1999) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception to see an out-of-network ear, nose, and throat (ENT) specialist (99214).
You asked the Plan to pre-approve the in-network exception. You say that the plan does not have providers that can be provide the requested INSPIRE device, therefore, the enrollee should be able to use an out-of-network provider at the in-network rate. The Plan denied your request. The Plan says coverage criteria has not been met for the INSPIRE Hypoglossal Nerve Stimulation device. Therefore, there are network providers available that can manage the enrollee's condition.
Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says that the plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.
Medicare rules also state that Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea is contraindicated in enrollees with a BMI of 35 kg/m2 or greater. The requested provider in this case is not a network provider with the Plan. The enrollee does not meet the coverage criteria for the requested INSPIRE procedure (a BMI of less than 35 kg/m2), therefore, plan ENT providers would be able to meet the enrollee's needs. The Plan has network providers available. We found no exception that would require the Plan to authorize the out-of-network visit at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve an in-network exception to see an out-of-network ear, nose, and throat (ENT) specialist (99214). Please note, the enrollee has out-of-network benefits and may utilize them to see the out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for Radiologic examination, chest (71045) provided March 25, 2021.
You asked the Plan to pay for the diagnostic services. You say that it is not always possible to confirm whether a patient has any allowance left before rendering services. The Plan denied your request. The Plan says that the maximum frequency has been exceeded.
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 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 records show that the provider billed for 1 unit of the service. The Plan has not provided any information regarding their reason to deny for exceeding maximum frequency. The Plan has not provided any information to substantiate their reason to deny Therefore, we decided that the Plan has to pay for Radiologic examination, chest (71045) provided March 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency department visit provided on May 20, 2021.

You asked the Plan to waive the copayment for Emergency department visit (99282). You say that you should not have needed this procedure. 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 $90 copayment for Emergency Care. 

You have been asked to pay a $90 copayment for Emergency department visit (99282). Emergency department visit (99282) falls within the Emergency Care 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 Emergency department visit provided on May 20, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) and office visit (99212) provided on May 5, 2021.
You asked the Plan to pay for the eye refraction (92015) and office visit (99212). You say that you get a glaucoma pressure check every six months and you should only have a $50 copayment for this procedure. The Plan denied your request. The Plan says the claim has processed correctly based on how the claim was billed. The diagnosis the provider billed is indicating this exam is routine eye exam.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file, the Plan's rules and Medicare's rules. The file shows that part of this exam was for an eye refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. The file also shows that the office visit was not billed with the code for a glaucoma screening. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) and office visit (99212) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on February 3, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.
We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on February 3,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laminectomy, facetectomy and foraminotomy (CPT)
code 63047), for the enrollee.
You asked the Plan to pre-approve the service. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found percutaneous image guided decompression remains experimental. More research is needed to
show safety and efficacy of the procedure. Also, there has not been an adequate trial and failure of conservative
measures for low back pain to include six (6) weeks of physical therapy (PT).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the laminectomy, facetectomy and foraminotomy (CPT) code 63047), for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance services (A0431-QL) provided on November 12, 2020.
You asked the Plan to pay for air ambulance services. You say that this was billed correctly. The Plan denied your request. The Plan says that this cannot be paid because the patient was not transported.
The Plan must follow Medicare rules. Medicare rules say that if the beneficiary is pronounced dead after takeoff to the point-of-pickup, but before the beneficiary is loaded, the appropriate air base rate is paid with no mileage or rural adjustment, and the QL modifier is used when submitting the claim. We looked at the file and Medicare rules. The records show that the beneficiary was pronounced dead after takeoff, and the air ambulance service was billed with the QL modifier. Based on this information, we decided that Medicare rules for coverage of air ambulance services have been met. Therefore, we decided that the Plan has to pay for air ambulance services (A0431-QL) provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the health plan's denial should be upheld. 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on March 15, 2021, March 19, 2021 and March 31, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that the secretary advised that the plan covered the services, but you received a bill for $350. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for each physical and speech therapy session.
You have been asked to pay a $25 copayment for each physical therapy visit. The total amount you owe is $75 ($25/visit x 3 visits = $75). Physical therapy falls within the "Outpatient rehabilitation services" 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 physical therapy provided on March 15, 2021, March 19, 2021 and March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services.
You asked the Plan to pay for the services. You say that you have suffered from neck pain for over two years. The Plan denied your request. The Plan says this is not a covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that one of the services at issue (98943) is not manual manipulation of the spine. Additionally, you have already received eighteen visits during the year, so additional visits cannot be covered. Therefore, we decided that the Plan does not have to pay for chiropractic 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis and surgical
management of a pelvic abscess. The enrollee's 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. 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. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for IRF 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 for the enrollee.