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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 preapprove 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 is an 86-year-old woman with a history of diabetes and hypertension, who underwent a right total knee arthroplasty on July 7, 2020. On July 22, 2020, the enrollee was brought to the hospital with weakness. Labs were consistent with acute kidney injury and a UTI. On July 27, 2020, the enrollee was improving. The PT and OT planned frequency was 3 times per week. The enrollee's sitting activity tolerance was 20 minutes. The medical records do not show the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not show the enrollee requires treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The documentation does not support that the enrollee would be able to tolerate at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services. Medicare coverage criteria are 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283), extraspinal manipulative treatment (98943), manual therapy techniques (97140) and application of electrical stimulation (97014) provided on January 2, 2020 through March 12, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because you were not informed of the provider's out-of-network status and believe these services should be paid to the provider. The Plan denied your request. The Plan says these services are not listed as covered under the chiropractic benefit in the EOC. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283), extraspinal manipulative treatment (98943), manual therapy techniques (97140) and application of electrical stimulation (97014) provided on January 2, 2020 through March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on April 20, 2020.You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 services 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 radiology services provided on April 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cardiac Computed Tomography (CT) with Calcium Scoring (75571).You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary.The Plan denied your request. The Plan says the rules for coverage of the CT scan have not been met.The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found based on the records the enrollee has increased coronary risk but no symptoms suggestive of coronary ischemia.  In this setting screening cardiac CT scanning with calcium scoring is not recommended and has not been shown to improve cardiac outcome.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve Cardiac Computed Tomography (CT) with Calcium Scoring (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forwound cover dressings provided on January 10, 2020.You asked the Plan to waive the coinsurance forwound care supplies. You say that you have been getting supplies for your wound for over a year and have always been covered.The Plan denied your request. The Plan says the coinsurance 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% coinsurance for wound care dressings. The allowed amount of the claim is $117.90, resulting in a coinsurance obligation of $23.58.You have been asked to pay 20% coinsurance for wound care supplies. Wound care supplies fall within the Outpatient Diagnostic Tests and Therapeutic Services andSupplies 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 coinsurance forwound cover dressings provided on January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 6, 2020.You asked the Plan to pay for drug tests. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the codes billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a pontic (D6242) for tooth #8 and retainer crowns (D6752 x2) for tooth #'s 7 & 9.You asked the Plan to pre-approve the ponticand retainer crowns. You say that you really need the bridges because the partial and denture do not work due to your overbite. You also say that they have adjusted your denture and partials, but they cannot be adjusted anymore because it is too thin now.The Plan denied your request. The Plan says that the information does not say why a denture cannot be used to replace your missing teeth.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 pontic and retainer crowns when the services are medically necessary and reasonable.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 pontic and retainer crowns. Our reviewer says that these services are medically necessary. Our physician reviewer found tooth #8 is missing and is currently being replaced by a mostly unusable partial denture, the pontic would be medically necessary and reasonable. Our reviewer also found that the retainer crowns for tooth #7 and #9 are medically necessary and reasonable as the existing appliance is not functional due to the occlusion, and fixed bridgework would be the reasonable treatment in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of thepontic and retainer crowns have been met.Therefore, we decided that the Plan has to pre-approvea pontic (D6242) for tooth #8 and retainer crowns (D6752 x2) for tooth #'s 7 & 9. 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 toopen 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 fordental services provided from September 20, 2019 through December 20, 2019.You asked the Plan to pay fordental services. You say that this was medically urgent and necessary not cosmetic. You say that you should be reimbursed.The Plan denied your request. The Plan says out-of-network dental services are not covered benefits.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, out-of-network dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fordental services provided from September 20, 2019 through December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.You asked the Plan to pre-approve the inpatient mental health services. You say that the inpatient services are medically necessary.The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care such as outpatient therapy.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that continued inpatient services are not medically necessary. Our physician reviewer found upon review the records provided, the enrollee does not meet the criteria for treatment in an acute inpatient mental health facility beyond the date in question of July 29, 2020. The enrollee can be treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, visual hallucinations, delusions, and was not showing any behaviors of aggression.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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records, there are no identifiable skilled nursing service needs.The records do not show a need for skilled nursing or skilled therapy services on a daily basis.Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.Medicare coverage criteria are 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pontic (D6245) and two retainer crowns (D6740 x2).You asked the Plan to pre-approvethe pontic and retainer crowns. You say that you had a bridge made in 1981 that is broken and food collects in it. You also say that your cardiologist recommends having this procedure done because bacteria can grow in these pieces and affect your heart.The Plan denied your request. The Plan says these services are 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-approvea pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure. You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee has had this procedure done several times in the past with more than 50% pain relief and increased function. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/investigational and not covered by Medicare. The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is only covered under the clinical indications listed 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 radiofrequency ablation. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested radiofrequency ablation procedure. Our physician reviewer found the documentation does not indicate that the enrollee has had at least 3 months of conservative care such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or physical therapy. The enrollee had a prior left sacral lateral branch radiofrequency ablation in 2016 with reports of 50% pain relief, however there is no documentation of objective measurable functional improvement in activities of daily living for at least 5 to 6 months after the procedure. Furthermore, a repeat radiofrequency neurotomy requires failure of other conservative measures without repeating medial branch block injections if the enrollee has experienced significant and prolonged relief of pain and improvement of function from previous radiofrequency ablation. The requested radiofrequency ablation procedure is not medically reasonable and necessary for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer board (E1399)You asked the Plan to pre-approve a transfer board. You say that this equipment is vital and to able to be transferred from your bed to a wheelchair since you cannot fend for yourself.The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a transfer board (E1399)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal facet rhizotomy services.You asked the Plan to pre-approve spinal facet rhizotomy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain indications.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 spinal facet rhizotomy services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee is taking Tramadol for pain. The enrollee had 2 Right SI joint injections and achieved 60% pain relief with the first injection and 90% pain relief on the second injection. The documentation supports that the requested service is considered an experimental/investigational procedure because of the wide variation in efficacy and technique reported in the peer reviewed literature. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal facet rhizotomy services have not been met.Therefore, we decided that the Plan does not have to pre-approvespinal facet rhizotomy services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Neulasta.You asked the Plan to pre-approve Neulasta. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Neulasta. Our reviewer says that the documentation supports that the requested drug, Neulasta is medically reasonable and necessary. Our physician reviewer found the enrollee has low grade Myelodysplastic syndromes and is on Vidaza. The documentation supports that the requested use of Neulasta is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use of this drug is supported both in the NCCN Guidelines Version 2.2020 Hematopoietic Growth Factors and the article. Overall survival and risk of second malignancies with cancerchemotherapy and G-CSF support. Ann Oncol 2018;29:1903-1910. Therefore, the enrollee meets criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have been met.Therefore, we decided that the Plan has to pre-approveNeulasta.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on November 14, 2019.You asked the Plan to pay fordrug test. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on June 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 items/services.Therefore, we decided that the Plan does not have to pay forlab services provided on June 19, 2019 by an out of network (OON) provider.