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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says Medicare guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another 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. 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 in an IRF at this time. The documentation does notreveal that the enrollee is medically stable to transfer and fully participate in an IRF program. The enrollee may benefit from and participate in additional physical therapy and occupational therapy, but the documentation does not support that the enrollee is medically ready for nor can he tolerate an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omega 3 Acid Cap 1gm.
You asked the Plan to pre-approve Omega 3 Acid Cap 1gm. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Omega 3 Acid Cap 1gm.
Benefits for Omega 3 Acid Cap 1gm 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift mechanism (E0627).You asked the Plan to pre-approvethe seat lift mechanism. You say that you need something to help you get up due to bilateral disability.The Plan denied your request. The Plan says coverage criteria for the seat lift mechanism have not been met.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.The file shows that you are able to get up from other chairs in your home. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift mechanism (E0627).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve deep sedation/general anesthesia for surgical extractions.
You asked the Plan to pre-approve the anesthesia. You say that this is medically necessary. The Plan denied your request. The Plan says that the codes submitted are not covered by 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. The Plan covers the anesthesia when the services are medically necessary and reasonable. This request for anesthesia is for surgical extractions. Surgical extractions are covered by your dental plan under the supplemental comprehensive dental benefits. The language of the Evidence of Coverage states that coverage supplemental comprehensive dental benefits "include minor restorations (fillings), simple extractions, dentures, and denture repair." It does not say that these are THE ONLY services that are covered by this benefit. Additionally, there are a few types of dental services that are specifically excluded in the Evidence of Coverage. Anesthesia is not one of them. Based on this information, we decided that the Plan's rules for coverage of the anesthesia have been met. Therefore, we decided that the Plan has to pre-approve deep sedation/general anesthesia for surgical extractions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing and genetic testing for Lynch Syndrome.You asked the Plan to pre-approvethese services. You say that you have a family history of cancer.The Plandenied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that BRCA and genetic testing for Lynch Syndrome are covered when specific criteria are met.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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a family history of colon cancer in your mother and cousin and uterine cancer in a sister. There is no documentation that you have a personal history of cancer. Genetic testing for Lynch Syndrome is not covered as screening for enrollees without a personal history of cancer. The testing is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. The file does not show that you have a personal history of cancer for which BRCA testing is covered. 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 pre-approveBRCA genetic testing and genetic testing for Lynch Syndrome
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from April 23, 2019 through April 29, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on April 23, 2019 and discharged on April 29, 2019. You were asked to pay a $350 copayment per day from April 23, 2019 through April 27, 2019, days 1-5 of your inpatient stay. Therewere no copayment charges from April 28, 2019, day 6 of your inpatient hospital care until your day of discharge April 29, 2019. Per your contract there is a $350 copayment per day required for days 1-5. 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 forinpatient hospital care from April 23, 2019 through April 29, 2019 provided by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox 200-unit injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says gastroparesis is not a medically accepted indication for Botox.
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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved compendia the use of Botox injections in this case is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Botox 200-unit injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) and intubation (31500) provided from
July 5, 2019 to July 7, 2019.
You asked the Plan to pay for critical care and intubation. You say that these codes are supported.
The Plan denied your request. The Plan says these codes are not supported in the record.
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 CPT Code Manual definition of code 31500 is intubation, endotracheal, emergency procedure
and 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes.
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 critical care and intubation. Our reviewer
says that CPT 31500 is not supported in the records. Our physician reviewer found the medical records
provided do not include documentation of intubation, endotracheal, emergency procedure being performed,
therefore, the service cannot be verified. CPT 99291 is also not supported. The records do not contain
documentation of the time spent on each critical care episode.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of critical care and intubation have not been met. Therefore, we decided that the
Plan does not have to pay for critical care (99291) and intubation (31500) provided from July 5, 2019 to July 7,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the colorectal screening provided on September 10, 2019.
You asked the Plan to waive the deductible for the colorectal screening. You say that you are being blocked from accessing your preventive service benefit. You say that the denial is incorrect. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your yearly deductible is $5,500. This is how much you must pay for your Part A and Part B services before the plan will pay for your covered services.
The item or service you asked the Plan to waive the copayment for falls within the "Colorectal cancer screening" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your yearly $5,500 deductible applies to the colorectal cancer screening. This cost sharing is a contractual obligation that had not been met at the time the colorectal screening was received on September 10, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the colorectal screening provided on September 10, 2019.
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 the enrollee has multiple issues and requires care and rehab. 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 enrollee was admitted to the hospital on February 10, 2020 with a femur fracture after a fall. She is waking 100 feet with a rolling walker and assistance. She needs assistance with toileting, moving from sitting to standing, and transfers. She is medically stable with no complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or acute rehab nursing care. She may benefit from further therapy but does 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for drug testing. You say that according to the provider, medical necessity has been established for this patient due to their diagnosis assessment. Due to the patient's primary diagnosis and the findings of the specimen results, the services rendered were medically necessary for the ordering physician to monitor any medication in use or misuse by the patient to further treat appropriately. The Plan denied your request. The Plan says this was ordered by a local physician who is not contracted with the Plan. Furthermore, lab services were not performed in an urgent care or emergency room setting. All lab services should be performed within the primary network. The Plan must give approval in advance before services can be provided with other providers in the Plan's network. This is a non-contracted provider who performed services to the member without prior authorization from the Plan.
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 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0480) provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visits provided on August 7, 2019 and August 28, 2019.
You asked the Plan to waive the copayment for the ED visits. You say that you did not want to go to the emergency room. You say that you want the Plan to help with the copayments. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 for each Medicare-covered emergency room visit.
You have been asked to pay a $110 copayment for each ED visit. The total amount you owe is $220 ($110/visit x 2 visits = $220). The ED visits falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ED visits provided on August 7, 2019 and August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve conduction studies/electromyography.
You asked the Plan to pre-approve the services. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found electrodiagnostic studies such as EMG/NCS are primarily used to evaluate the integrity and function of the peripheral nervous system. In this case you are noted to have a history of generalized osteoarthritis. The examination notes provided for review only document a history of osteoarthritis. There were no problems noted on examination related to the peripheral nerves. There were otherwise no signs/symptoms/findings to suggest that you had a problem involving the nervous system. Inasmuch it cannot be said that an EMG/NCS would be appropriate for your presentation. Nor would said services be furnished in a manner appropriate to your medical needs and condition. In as much this service would not be 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve nerve conduction studies/electromyography.
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 needs IRF level care. The Plan denied your request. The Plan says the enrollee could be treated in another 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. 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 in an IRF. The documentation reveals the enrollee's medical issues in the acute care hospital have not resolved. It is not clear that the enrollee is medically ready for a transfer to a rehabilitation facility. The patient may benefit and participate in additional physical and occupational therapy but the patient is at a high functional level that does not require this therapy on an intensive rehabilitation facility therapy program level 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve the Gel-One. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation does not support the
medical necessity for a step therapy exception.
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 the Gel-One. Our reviewer says that the
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Our physician reviewer
found without the support of the documentation, Gel-One is not approved as step criteria is not met.
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 Gel-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an assessment for a power operated vehicle.You asked the Plan to pre-approvethe assessment. You say that you are having difficulty maneuvering around your home and have poor balance which has resulted in falls. The Plan denied your request. The Plan says The notes do not show that the mobility device is needed to complete daily activities within the home.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker,cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 assessment. Our reviewer says that the documentation does not reveal that this limitation significantly impairs your ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The physical therapy document notes that you have not attempted use of a rollator to assist with in home mobility. The documentation does not reveal that this mobility limitation is unable to be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. Our physician reviewer found the documentation does not reveal a home assessment that indicates you are safe to use a power mobility device in the home. Thepower operated vehicle 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 the assessment have not been met. Therefore, we decided that the Plan does not have to pre-approve an assessment for a power operated vehicle.