Persius/hicric huggingface dataset:
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 that you were admitted for elective total hip replacement. 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 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 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 acute inpatient rehabilitation facility (IRF) admission and 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.
You asked the Plan to pre-approve IRF care. You say that transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in a less intensive setting.
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 that 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. 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 enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup provided on March 16, 2021 and crowns provided on April 2, 2021.
You asked the Plan to pay for the core buildup and crowns. You say that you were told they in were in-network and they take your insurance. You say that you would not have gone there if you were not covered. The Plan denied your request. The Plan says out-of-network dental services are 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup provided on March 16, 2021 and crowns provided on April 2, 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 enrollee would benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee would not benefit from an intensive rehabilitation program and does not have complex medical management needs.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of right tib-fib fracture after a motorcycle accident. His medical problems are stable.
He does not require treatment by multiple therapies in 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 waive the cost sharing for the arthrocentesis procedure and the methylprednisone acetate injection received in a specialist's office on May 13, 2021.

You asked the Plan to waive the cost sharing for the arthrocentesis procedure and methylprednisone acetate injection. You say that you believe these charges are not allowed. The Plan denied your request. The Plan says this cost sharing was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for surgery services and 20% coinsurance for Medicare Part B drugs in a specialist's office.

The enrollee has been asked to pay a $25 copayment for the arthrocentesis procedure and 20% coinsurance for the methylprednisone acetate injection. This means that the enrollee has been asked to pay the correct amounts based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the arthrocentesis procedure and the methylprednisone acetate injection received in a specialist's office on May 13, 2021.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Lucentis (J2778).

You asked the Plan to pre-approve Lucentis. You say that this drug is medically necessary to prevent the patient from going blind. The Plan denied your request. The Plan says that step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Lucentis. Our reviewer says that the requested drug is medically necessary and reasonable. Our physician reviewer found that the enrollee has a diagnosis of exudative age-related macular degeneration, right eye, with active choroidal neovascularization. The enrollee's retinal specialist writes that Lucentis has been shown to be statistically more effective than Avastin in a large randomized controlled clinical trial treating Neovascular age-related macular degeneration with Active Choroidal neovascular membranes. It is states that the enrollee has a high risk of going blind, and that the use of Avastin wastes precious time in salvaging patients' vision. The documentation by the prescribing physician supports that the plan's required drug(s) would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Lucentis have been met. Therefore, we decided that the Plan has to pre-approve Lucentis (J2778).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided March 17, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided March 17, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the target genomic sequence analysis panel provided on February 3, 2021.

You asked the Plan to pay for the services provided. You say that the tests were needed to help determine the course of treatment for this enrollee. The Plan denied your request. The Plan says the service is non-covered by Medicare.

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. The file shows that F1Heme testing was performed and billed with CPT Code 81455. The rules say that genetic testing procedures submitted under the CPT code 81455 is unlikely to impact therapeutic decision-making in the clinical management Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the target genomic sequence analysis panel provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and Pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) to be provided by an out of network provider.
You asked the Plan to pre-approve the out-of-network DME. You say that the out-of-network DME is necessary. The Plan denied your request. The Plan says the enrollee meets the criteria for use of CPT code(s): E0652 and E0667; however, there are in-network providers that can render the DME.
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 segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and Pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) to be provided by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits.

You asked the Plan to pre-approve 5 additional home health skilled nursing visits. You say that home health services are medically necessary. The Plan denied your request. The Plan says the criteria for home health skilled nursing care have not been met.

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 5 additional home health skilled nursing visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. There is no evidence of complex wound care, new enteral feedings, a recent significant change in patient's medical condition. The patient has had education on disease and medication management and safety. There are no skilled nursing needs present that would require additional home health visits. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0483) rendered by the out-of-network (OON) provider on February 16, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0483) rendered by the out-of-network (OON) provider on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan denied your request. The Plan says 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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. The medical records consist of 1) the order for the ventilator and 2) overnight oximetry. A diagnosis of chronic obstructive pulmonary disease (COPD) is stated in the order, but there is no clinical information to support this. There is no diagnosis of neuromuscular disease or thoracic restrictive disease. There is no evidence that BiPAP has been tried, and there is no documentation of carbon dioxide (CO2) retention. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker purchased on February 17, 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 provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 

We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the walker purchased on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for three surgical tooth extractions (D7210) provided on February 26, 2021.
You asked the Plan to pay for the surgical extractions. You say that you received bills for these services and feel they should be paid. The Plan denied your request. The Plan says that these extractions were provided in an inpatient hospital setting. Per your dental benefits, hospitalization for any dental procedure is 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. The Plan covers the surgical extractions once per tooth. You pay 50% coinsurance for these services.
The rules also 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. We looked at the file and Medicare rules. The Plan denied these services on the basis that the request is for inpatient services for a surgical dental procedure. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Based on the limited information provided by the Plan, the services in question are three separate surgical tooth extractions, each billed with code D7210. It appears that these services are the ones being denied by the Plan. In addition, there are no records provided to support that these services were provided in an inpatient setting or that these services were not provided for a procedure that is covered by Medicare. Based on this information, we decided that the Plan's rules for coverage of the surgical extractions have been met. Therefore, we decided that the Plan has to pay for the surgical tooth extractions (D7210) provided on February 26, 2021.
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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF, and a
transfer is medically necessary. The Plan denied your request. The Plan says criteria for admission to an IRF
are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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. Our
physician reviewer found that 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. 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 enrollee
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.