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

We decided that the Plan does not have to pay for an inpatient admission.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no condition that warrants this admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case the record does not demonstrate that the admitting physician expected the hospital stay to span two midnights. The record does not indicate that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you have had success with this doctor in the past. You say that you would like to use this doctor again. The Plan denied your request. The Plan says there are in-network providers available for these 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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).
You asked the Plan to pre-approve Superion interspinous spacer (Vertiflex device). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Superion interspinous spacer (Vertiflex device). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain from spinal stenosis. The Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion interspinous spacer (Vertiflex device) have not been met. Therefore, we decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is a safer alternative than a laminectomy. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. Vertiflex has never been shown to be safer than laminectomy in the peer reviewed literature. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a psychiatric evaluation with a bariatric surgeon for the enrollee.
You asked the Plan to pre-approve the evaluation. You say that this is medically necessary. The Plan denied your request. The Plan says there is an absence of significant cognitive impairment or other complex medical conditions affecting the enrollee's functioning.
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 evaluation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, no diagnostic interview session has been performed. No specific indication for detailed testing has been established. 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 evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve a psychiatric evaluation with a bariatric surgeon for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair and related accessories.
You asked the Plan to pre-approve the group 3 power wheelchair and related accessories. You say that this item is necessary for your medical condition. The Plan denied your request. The Plan says the request for the group 3 power wheelchair is not medically necessary.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair and related accessories.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health partial hospitalization (20 hours per week) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show severe symptoms.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is found to be calm, cooperative with adequate grooming skills and psychomotor activity. She did not have any mood disturbance or psychotic symptoms. The enrollee needs treatment in a community-based outpatient clinic setting. All told, the requested partial hospitalization services are not medically necessary for the treatment of this enrollee for the dates in question beginning May 9, 2020 forward. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve mental health partial hospitalization (20 hours per week) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound examination of the heart for the enrollee.
You asked the Plan to pre-approve the exam. You say that this is medically necessary. The Plan denied your request. The Plan says there are no suggestions of structural cardiac change.
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 exam. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is well compensated at this time without any symptoms. The provided medical record does not address the rationale for an echocardiogram at this time. A routine echocardiogram is not medically reasonable or necessary in an enrollee with compensated symptoms following an exacerbation. 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 exam have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasound examination of the heart for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not on insulin. The enrollee's family member checks the enrollee's blood sugar once or twice a day. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 acupuncture visits (97810, 97811) for the treatment of migraine headaches.
You asked the Plan to pre-approve acupuncture. You say that the medical records provided support the necessity of the service in dispute. The Plan denied your request. The Plan says this is not a covered benefit. Medicare only covers acupuncture for chronic low back pain. This is not covered for headaches.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, this service is only covered for the treatment of back pain. Therefore, we decided that the Plan does not have to pre-approve 4 acupuncture visits (97810, 97811) for the treatment of migraine headaches.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a soft occlusal guard (D9945) to wear at night.
You asked the Plan to pre-approve the occlusal guard. You say that this guard is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or by the Plan's supplemental dental 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 pre-approve a soft occlusal guard (D9945) to wear at night.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) with the Watchman device for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a CHADS-Vasc score of 3 and a HASBLED score of 3. He requires anticoagulation for his atrial fibrillation. The note dated October 2020 indicates that he does not have any of the main indications for the Watchman. The record does not indicate that he is suitable for warfarin. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) with the Watchman device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of chronic intertrigo.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the medical record does not provide a description or photographs of the extent of the pannus or presence of intertrigo. The provided records do not show that three months of conservative therapy have failed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature shows that this is considered experimental and investigational.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Myopro Motion G orthotic device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device has deluxe features that exceed medical needs.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the medical records provided do not indicate the type of device the physician is ordering or the rationale for the order. The medical necessity and reasonableness of the requested service cannot be established from the documentation provided. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Myopro Motion G orthotic device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient office visit (99214) interrogation device evaluation(s), (remote) up to 30 days (93298) duplex scan of extracranial arteries (93880) provided October 21, 2020 to November 23, 2020.
You asked the Plan to waive the copayment for the office visit and diagnostic services. You say that you are appealing the EOB's for these charges asking you to pay $35, $105 and $25. The Plan denied your request. The Plan says these claims were processed, and the correct copayment was applied per the Evidence of Coverage.
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 $25 copayment for non-radiological diagnostic services, $105 copayment for each radiological diagnostic service and $35 copayment for services obtained from a specialist. You have been asked to pay $165 ($25+$105+$35) for the office visit and diagnostic services. The office visit and diagnostic services falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies and Physician/Practitioner Services, including Doctor's Office Visits benefit categories. 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 outpatient office visit (99214) interrogation device evaluation(s), (remote) up to 30 days (93298) duplex scan of extracranial arteries (93880) provided October 21, 2020 to November 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 transportation trips.
You asked the Plan to pre-approve an additional 10 transportation trips. You say that you would like the Plan to pre-approve more trips. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
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 a maximum of 24 transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 10 transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the infusion of methylprednisolone, every day, for 5 days.
You asked the Plan to pre-approve the methylprednisolone infusions. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for the requested parenteral therapeutic modality.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 methylprednisolone infusions. Our reviewer says that the infusion of methylprednisolone rather than orally is not medically necessary. Our physician reviewer found there is an abundance of medical literature available to support the use of IVMP in multiple sclerosis (MS) exacerbations and/or relapses. The reviewer found that this is generally regarded as a safe and effective treatment. However, the reviewer found that the provided documentation did not readily support that the enrollee would be unable to take/use oral steroids. The reviewer found that oral steroids have otherwise been shown to be as beneficial as IV steroids in the management of MS exacerbations and relapses. Therefore, the reviewer found that the infusion of methylprednisolone rather than orally is not medically reasonable or 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 methylprednisolone infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve the infusion of methylprednisolone, every day, for 5 days.