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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Myocardial Perfusion Imaging test (78452).
You asked the Plan to pre-approve a Myocardial Perfusion Imaging test (78452). You say that the requested
Myocardial Perfusion Imaging test is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for the requested Myocardial Perfusion Imaging test.
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 Myocardial Perfusion Imaging test
(78452). Our reviewer says that the enrollee does not meet criteria for the requested Myocardial Perfusion
Imaging test. Our physician reviewer found myocardial perfusion imaging (SPECT) is requested for further
evaluation of coronary artery disease in this enrollee with an elevated coronary calcium score of 951 (83% for
age). It is noted that the enrollee is very active, and is asymptomatic. Cardiac risk factors include smoking and
hypercholesterolemia. Electrocardiogram revealed sinus bradycardia, but was otherwise normal. Based on a
review of the documentation provided and Local Coverage Determination (LCD) - Cardiovascular Nuclear
Medicine (L35083), the requested study 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 a Myocardial Perfusion Imaging test (78452) have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Myocardial Perfusion Imaging test (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TheraSkin wound care.You asked the Plan to pre-approve TheraSkin. The Plan denied your request. The Plan says the safety and effectiveness for the enrollee's condition has not been established.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 TheraSkin. Our physician reviewer found that the enrollee is noted to have post-operative wounds, following the removal of squamous cell skin cancer. The wounds have been decreasing in size and appear to be responding to standard therapy. Therefore, the requested TheraSkin is not shown to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin have not been met. Therefore, we decided that the Plan does not have to pre-approve TheraSkin wound care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray consultation (76140) provided on January 14, 2020.
You asked the Plan to pay for the x-ray consultation. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says CPT code 76140 has a status code of I which is
not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 76140 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 76140 has a status code of I. This means that CPT code 76140 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the x-ray consultation have not been met.
Therefore, we decided that the Plan does not have to pay for an x-ray consultation (76140) provided on January
14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.
You asked the Plan to pre-approve these services. You say that the enrollee needs the medication for quality of
life. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on January 1, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because you do not feel the doctor you saw was very good. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $50 copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on January 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that generally; you will only be referred to a doctor outside of the Plan's medical group if the in-plan specialists cannot provide the care you need. 
 
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's 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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 above. 
 
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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on June 2, 2020 for knee surgery. You are currently medically stable and need minimal to moderate assistance with dressing and functional transfers. You have no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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 pre-approve 99 additional routine transportation trips.
You asked the Plan to pre-approve these services. You say that you have several upcoming doctor appointments. The Plan denied your request. The Plan says you have exhausted the benefit limit.
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 one-way 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 99 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additions of a tooth to an existing partial denture (D5650 x2) provided on March 16, 2020.
You asked the Plan to pay for the additions of a tooth to an existing partial denture. You say that these services should be $0 copays. The Plan denied your request. The Plan says this service is not covered under the 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two additions of a tooth to an existing partial denture (D5650 x2) provided on March 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee's medical issues are stable, and there is no need for complex wound care.
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 continued services. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, care, or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain his condition, or prevent deterioration. There is no evidence of new enteral feedings, complex wound care, or IV antibiotics. The enrollee's medical conditions are chronic and stable, and he should be educated in disease management at this point. The medical records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve his level of function, to maintain his level of function, or prevent deterioration. The enrollee has not had a recent therapy evaluation indicating a need for skilled therapy services. There has been no evidence of a significant decline in functional status. As the request for skilled nursing and skilled therapy is not medically necessary, home health care cannot be considered 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Olumiant 2mg tablet for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.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 Olumiant 2mg tablet for the enrollee.
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 it is felt that the IRF level of care would be best. The
Plan denied your request. The Plan says the enrollee's condition does not require this level of care as she is
medically stable and does not require an intensive therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee is ambulating more than 100 feet at a time. The enrollee's 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not indicate that this therapy must be in an IRF with an intensive level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897)
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy encourages you to try zoledronic acid, which is just as effective.
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 Prolia. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no indication of a trial and failure of the required drug. The provided medical records do not indicate that the required drug would likely be less effective and/or likely have adverse effects for the 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Megestrol Acet 40mg/ml SUSP for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Megestrol Acet 40mg/ml SUSP for the enrollee.
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. The Plan denied your request. The Plan says that this patient does
not meet medical necessity criteria that requires a high level of physician supervision in combination with
therapy services in an inpatient 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 above.
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
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care
needs can be met at a lower level of care. 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 Lokelma Pak 10mg.
You asked the Plan to pre-approve the drug. You say that the enrollee needs this medication, otherwise they are at a higher risk for heart arrythmia and heart attacks. The Plan denied your request. The Plan says this drug is not covered under the plan under any normal circumstances.
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 Lokelma Pak 10mg.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 28, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you did not see the doctor. You say that you shouldn't owe the copayment. The Plan denied your request. The Plan says the copayment 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 $45 copayment per visit. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were seen to establish care for chronic kidney disease. 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 the office visit provided on February 28, 2019.