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 you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.

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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need
for physical and occupational therapies, but not for an intensive rehabilitation program. Medically necessary
services could be provided in a lower level of care. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor with single-day imaging.

You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is being evaluated for cardiac amyloidosis. A number of tests have been ordered in parallel, rather than in series with the results of initial tests guiding the ordering of subsequent tests. Nuclear imaging has been ordered prior to documenting the results of monoclonal light chain screening. The documentation therefore does not support that the requested imaging is reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. 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-approve radiopharmaceutical localization of tumor with single-day imaging.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939) and orthofix trinity allograft (20930).

You asked the Plan to pre-approve a bone marrow aspirate and orthofix trinity allograft. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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 a bone marrow aspirate and orthofix trinity allograft. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration and/or allograft in conjunction with the planned cervical spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate and/or allograft for this enrollee's medical condition.

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 bone marrow aspirate and orthofix trinity allograft have not been met. Specifically, there is no evidence these services are medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspirate (20939) and orthofix trinity allograft (20930).
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 requested IRF care is not medically necessary. Our physician reviewer found the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She was admitted for surgical treatment of a cervical fracture after a fall. Her medical problems are stable and there are no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. There is a not 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing.

You asked the Plan to waive the copayment for lab tests. You say that you have never had to pay anything for
bloodwork before, and this was done at the doctor's office. The Plan denied your request. The Plan says the
copayment amount you are being charged is correct.

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 $20
copayment for lab tests provided by a freestanding laboratory. This provider is considered to be a freestanding
laboratory, so the freestanding lab copayment applies to this claim.

You have been asked to pay $20 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests
and Therapeutic Services and Supplies 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 laboratory testing.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the breast for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that this is the best way to find a diagnosis for treatment.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has persistent abnormal physical findings and symptomatic complaints confined to one quadrant of the left breast. Conventional imaging including targeted ultrasound has been negative. Symptoms and physical findings have persisted without focal mass. Due to the above scenario MRI is the next procedure of choice with which to evaluate a clinically symptomatic patient in the face of negative conventional imaging. In addition since no focal mass is palpable biopsy is not indicated without further workup with MRI.

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the breast for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical
procedures provided on September 18, 2020.

You asked the Plan to pay for the local anesthesia. You say that you would like this service to be covered. The
Plan denied your request. The Plan says this service is not a covered benefit under your 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 local
anesthesia in conjunction with operative or surgical procedures provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electrical connection between two systems (E2311).

You asked the Plan to pre-approve the electrical connection. You say that you would like reconsideration because without this connection, the member will not be able to operate any of the power seat functions. The Plan denied your request. The Plan says there is not a medical need for the member to control the two requested power options through the joystick.

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 electrical connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the member requires other types of proportional input devices or non-proportional input devices. The member does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The member's strength and function in the upper extremities are sufficient for her to control any power options through their own switches.

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 electrical connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the electrical connection between two systems (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says an intensive rehabilitation program is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
cellulitis. 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. The medical record documents a need for physical and occupational
therapy but not for an intensive rehabilitation program. Medically necessary services could be provided in a
low level of care. There is a not 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite of two surfaces and resin-based composite of three surfaces.

You asked the Plan to pay more for the resin-based composites. You say that each time you contacted the Plan you were advised that you would receive 100% reimbursement for any claims filed if your dental allowance had not been exceeded. You also say that you would like to be reimbursed in full for these services. The Plan denied your request. The Plan says your dental reimbursement has been exhausted for the 2020 plan year.

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 Plan offers a dental allowance of $1,000 every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract clearly states that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing the claim for the date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the resin-based composite of two surfaces and resin-based composite of three surfaces.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay injection services (96372) provided to the enrollee.

You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says his is an exact duplicate claim/service (96372) the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated (J1642).

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, this claim cannot be paid due to prior submission and payment, which the Plan has provided in documentation. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay injection services (96372) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed.

You asked the Plan to pre-approve the semi-electric hospital bed. You say that you would like reconsideration because the member is not able to walk, and it takes two people to lift him in and out of the wheelchair. The Plan denied your request. The Plan says the records do not show that the member's condition requires positioning of the body, special attachments that cannot be fixed and used on an ordinary bed, frequent change in body position and/or there may be an immediate need for a change in body position.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 semi-electric hospital bed. Our reviewer says that the request for a semi-electric hospital bed is not medically necessary. Our physician reviewer found the documentation does not clearly reveal that member's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. 

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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs are unable to be
managed at a lower level of care. The Plan denied your request. The Plan says the denial of authorization for
LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found as LTACHs and acute care hospitals are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute
care hospital until such time as no acute services are required, then be transferred/discharged to 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria. 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 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 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. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided at a lower level of care. There is a not 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.

You asked the Plan to pre-approve these services. 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. Medicare rules say that a manual wheelchair is 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
mobility limitation but that it does not significantly impair your ability to participate in one or more mobilityrelated
activities of daily living (MRADLs) in the home. Your mobility limitation can be sufficiently helped by
the use of a walker. The records show that you would like the wheelchair for use outside of the home. The
services are not reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Furthermore, the file shows that the manual
wheelchair is being requested for use outside of the home and Medicare does not cover this equipment for this
purpose. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.