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

 
We decided that the Plan does not have to waive the copayments for the office visit you had with a specialist on 
May 12, 2021, and the sleep study you had on June 1, 2021. 
 
You asked the Plan to waive the copayments for the specialist visit and the sleep study. You say that in order to 
get a new breathing machine, you had to get a sleep study done.  You said that the doctor told you insurance 
would cover it in full, but then you received a bill. The Plan denied your request. The Plan says you were 
charged these copayments 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 $45 
copayment for visits with a specialist and a $25 copayment for outpatient diagnostic procedures and tests.  
 You have been asked to pay a $45 copayment for the specialist visit and a $25 copayment for the sleep study. 
The sleep study falls within the outpatient diagnostic procedures and tests benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. These cost sharing 
amounts are clearly laid out in your Evidence of Coverage. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for the office visit you had with a specialist on May 12, 2021, and the sleep study you had on June 
1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional OT visits.
You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is 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 ten (10) additional OT 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The limited medical records provided do not document any progress with functional activity or activities of daily living from the twenty OT visits already approved. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program and/or assistance from caregivers appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (power tilt and power recline).
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options (power tilt and power recline). You say that the requested group 3 power wheelchair with multiple power options (power tilt and power recline) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria.
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 a group 3 power wheelchair with multiple power options (power tilt and power recline). Our reviewer says that the enrollee does not meet criteria. Our physician reviewer found the documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of daily living (MRADLs) in the home and is not ameliorated by a walker, cane, manual wheelchair due to upper extremity weakness. While the enrollee may be able to safely operate a power mobility device (PMD) the requested Group 3 power wheelchair with multiple power options exceeds the enrollee's medical need. The documentation does not reveal that the enrollee's needs are at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the left upper extremity supports that the enrollee should be able to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary therefore the request for Group 3 power wheelchair with multiple power options 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 a group 3 power wheelchair with multiple power options (power tilt and power recline) have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (power tilt and power recline).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the inpatient care provided from September 9, 2020, to September 15, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the diagnosis code was accurate. The Plan denied your request. The Plan says the documentation does not support the billing of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code, I50.31, acute diastolic (congestive) heart failure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with ICD-10-CM code, I50. 31, acute diastolic (congestive) heart failure. 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 an additional amount for the inpatient care. Our reviewer says that the billing of the ICD-10-CM code, I50. 31, acute diastolic (congestive) heart failure has not been supported. Our physician reviewer found that the diagnosis code is being validated with a cardiology note from 9 months prior to the enrollee's admission. The reviewer found that the enrollee did not have any testing done to support acute congestive heart failure. The reviewer found that the enrollee displayed no symptoms of acute congestive heart failure (CHF). The reviewer found there was no treatment documented specific for heart failure beyond the enrollee's normal diuretic treatment. Therefore, the reviewer found that the documentation did not support the billing of ICD-10-CM I50. 31, acute diastolic (congestive) heart failure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient care provided from September 9, 2020, to September 15, 2020.
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 member's nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 surgical repair of a rectovaginal fistula. 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for deep vein thrombosis. The 
Plan denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Xarelto for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 8, 
2021. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the first dentist did an 
evaluation ad refused to pull the tooth. You say that the second limited oral evaluation was required. The Plan 
denied your request. The Plan says the service exceeds the frequency limitation in the benefit plan. 
 
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, you also have a maximum benefit of 
one limited oral evaluation every year. The Plan paid for the limited oral evaluation provided on June 15, 2021, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick Urinary Collection System to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Purewick Urinary Collection System. You say that the item is medically 
necessary. The Plan denied your request. The Plan says their network provider does have urinary drainage 
systems that the member can use. 
 
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 Purewick Urinary Collection System to 
be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), caries risk assessment 
and documentation (D0601), and periodontal maintenance (D4910) provided on July 27, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, caries risk assessment and documentation, and 
periodontal maintenance. You say that you have seen this dentist several times and have not had a problem 
until this visit on July 27, 2021. You also say that you found out after the services were rendered that this 
provider was no longer in-network, and you were not advised of this when you were there on this date of 
service. The Plan denied your request. The Plan says non-emergency services provided by an OON provider 
are not available with your dental plan. 
 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 pay for the periodic 
oral evaluation (D0120), caries risk assessment and documentation (D0601), and periodontal maintenance 
(D4910) provided on July 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Corus coronary artery disease (CAD) testing.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the manufacturer has failed to demonstrate that testing resulted in improved patient outcomes or that testing changed physician management to result in improved patient outcomes.

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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

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 specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for Corus coronary artery disease (CAD) testing.

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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that that Keytruda is not being prescribed for a medically-accepted 
indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that 
Keytruda is medically reasonable and necessary for the enrollee. Keytruda is FDA-approved for recurrent 
esophageal cancer for 2nd line therapy. Keytruda is safe and effective and otherwise reasonable and necessary 
for this enrollee. Our physician reviewer found that the enrollee's condition meets criteria for coverage of 
Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda for the enrollee.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that there are other services available to the enrollee at a lower level of care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on November 4, 2021, with Major Depressive Disorder, Recurrent, Unspecified. Based upon review the records provided it was not expected you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. It does not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.