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

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia andhypoxemia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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-approveacute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that further delay in transferring the enrollee to an LTACH will directly jeopardize her ability to fully recover and successfully regain maximum independence.The Plandenied your request. The Plansaysthe enrollee's needs can be provided in the hospital setting where she is now. LTACH would provide no clinical advantage.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 the enrollee was admitted on 10/31/20 with concerns for left upper compartment syndrome. Her hospital course has been complicated by persistent hardware infections and hardware was removed on 12/9/20. She developed acute encephalopathy and required intubation 12/15/20 and now has a trach and PEG tube. She required a chest tube for a pleural effusion on 1/15/21 which was later removed. She has tolerated a trach collar since 1/20/21. Recent Chest X-rays show that there is interval increase in the left pleural effusion which could be atelectasis or pneumonia. Her mental status remains tenuous and she opens her eyes to voice and has spontaneous movement of her right upper extremity.There is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveplacement of the Superion interspinous spacer.You asked the Planto pre-approvethe Superion procedure. You say that it is felt that this procedure is medically necessary to treat the enrollee's condition.The Plandenied your request. The Plansaysthis is not a proven procedure at this time.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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer remains experimental. More research is needed to show safety and efficacy. Additionally, there is no documented spinal instability. Hardware and stabilization are not needed.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Superion procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveplacement of the Superion interspinous spacer
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe initial 15 minutes of conscious sedation (D9239) and the 3 additional 15 minutes of conscious sedation (D9243).You asked the Plan to pre-approvethe dental services. You say that you need these services.The Plan denied your request. The Plan says conscious sedation is not listed as a covered service. The Plan also says that if a dental item or service is not listed in the benefit chart then it is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe initial 15 minutes ofconscious sedation (D9239) and the 3 additional 15 minutes of conscious sedation (D9243)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily therapy.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 Planwas correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the acute hospital for lumbar compression fracture after a fall. You havebeen discharged home with home health services,and has ongoing weakness. Your medical conditions are stable. The complexity of yournursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on June 25, 2020.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lightweight high strength manual wheelchair for the enrollee.You asked the Plan to pre-approvethe wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says needs must be able to be met with the required specifications of this wheelchair.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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates the enrollee has a mobility limitation,but it is not clear that this deficit significantly impairs the ability to complete MRADLs and is unable to be resolved by a walker. The documentation is not clear that the enrollee's home is appropriate for the wheelchair or that the manual wheelchair will significantly improve the enrollee's ability to participate in MRADLs. There is no trial of the wheelchair indicating the patient or caregiver can safely propel the wheelchair. The documentation does not support the enrollee cannot perform activities in the home ina standard wheelchair. The documentation does not reveal a need for a seat width/depth/weight that cannot be accommodated on a standard wheelchair.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea lightweight high strength manual wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that this is necessary for you to regain strength.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approverepair of a shower chair with casters (E1399 x7 and K0739 x4).You asked the Plan to pre-approvea shower chair. You say that the member needs the chair repaired.ThePlan denied your request. The Plan says this is hygienic equipment and is not medical in nature.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approverepair of a shower chair with casters (E1399 x7 and K0739 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on October 15, 2020.You asked the Plan to waive the copayment fora CT scan. You say that you cannot afford the charges.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 20% coinsurance up to a maximum of $75 for diagnostic radiology services. You have been asked to pay $75 for a CT scan. A CT scan falls within the outpatient diagnostic 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 fora CT scan provided on October 15, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent annual wellness visit provided on September
9, 2020.
You asked the Plan to pay for the subsequent annual wellness visit (G0439). You say that the Plan should pay
this claim. The Plan denied your request. The Plan says annual wellness visits are only covered once every
twelve months and you had an AWV on June 1, 2020.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Therefore, we decided that the Plan does not have to pay for the subsequent annual wellness visit provided on
September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the inserts will slow the progression of painful
bunion deformity.
The Plan denied your request. The Plan says the requested insert is not on a shoe that is an integral part of a
covered brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET imaging; whole body (CPT Code 78813).
You asked the Plan to pre-approve the PET scan. You say that the scan is necessary. The Plan denied your request. The Plan says the scan is not necessary and the rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer found there is no evidence in the notes provided to justify PET of brain. You must be with recent MRI of brain with no disease activity noted. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET imaging; whole body (CPT Code 78813).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvecardiac catheterization with angiography.You asked the Plan to pre-approvethe cardiac cath procedure. You say that the records provided support the need for the service in dispute.The Plan denied your request. The Plan says that the enrollee has not met the medical need criteria.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 cardiac cath procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient is at very high risk for underlying coronary artery disease. His advanced age, renal insufficiency, hypertension, hyperlipidemia, and diabetes make this so. He has symptoms (new onset dyspnea on exertion) which can be an anginal equivalent. He reportedly had rales on his baseline lung exam and was started on Lasix at that time and has frequent ventricular ectopy on his EKG. Although he doesn't have evidence of myocardial perfusion abnormalities on nuclear scan, his ejection fraction is at the low end of the normal range and he could certainly still have multi-vessel CAD given his underlying risk, physical findings and symptoms which could be masked as "balanced" ischemia on the Lexiscan nuclear study giving normal tracer perfusion.Given the constellation of symptoms, cardiovascular risk, and physical and imaging findings, furtherassessment for left main or multi-vessel coronary artery disease is clinically reasonable in this patient.Cardiac catheterization is therefore reasonable and medically necessary to further assess the symptoms and non-invasive clinical findings and this meets Medicare criteria for safety, effectiveness and medical necessity.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 cardiac cath procedure have been met.Therefore, we decided that the Plan has to pre-approvecardiac catheterization with angiography.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 ifthere 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided on October 20, 2020.You asked the Plan to pay forthe Guardant360 testing. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.The Plan must follow Medicare rules. Medicare rules say one unit of CPT code 81479 is used to report Guardant360 testing.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, there is a more appropriate CPT code used to report Guardant360 testing.Therefore, we decided that the Plan does not have to pay forGuardant360 testing provided on October 20, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRA of the neck for the enrollee.You asked the Planto pre-approvethe MRA. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical information does not document anticipated surgery, or new signs and symptoms consistent with carotid artery disease.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 MRA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the clinical information does not document anticipated surgery (patient currently stable with no recurrent syncope) or new signs/symptoms suspicious for carotid disease.  Moreover the carotid ultrasound reports normal left anterograde vertebral flow without report of high velocitiessuggestive of 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 MRA have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRA of the neck for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80307, G0483) provided on July 16, 2020.
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your
request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a
sample in its laboratory shows "81" as place of service.
We looked at the file and Medicare rules. The record shows that the specimen at issue was not taken in the
laboratory. The billing of these services with POS 81 is not appropriate. The service Based on this information,
we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided
that the Plan does not have to pay for laboratory services (80307, G0483) provided on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea shower chair.You asked the Planto pre-approvea shower chair. You say that your PCP wrote the prescription for the shower chair as you fell in the shower.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plandoes not haveto pre-approvea shower chair