Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high intensity focused ultrasound (HIFU) treatment.
You asked the Plan to pre-approve HIFU treatment. You say that this should be covered because it is non-invasive and seems to have better results. The Plan denied your request. The Plan says this is not a recurrence and you haven't been treated with radiation therapy.
The Plan follows Medicare rules. Medicare rules say that HIFU is considered medically necessary as a local treatment for recurrent PCa following radiation therapy. 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 HIFU treatment. Our reviewer says that the coverage criteria have not been met for the requested treatment. Our physician reviewer found high intensity focused ultrasound (HIFU) treatment is not covered as an initial treatment for localized prostate cancer as is the situation in this case. Coverage is limited to a salvage setting for recurrent prostate cancer following failed radiation treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HIFU treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve high intensity focused ultrasound (HIFU) treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that it is felt that acute rehabilitation would be the ideal setting for this enrollee. The Plan denied your request. The Plan says there is no need for acute medical care or three hours of 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 Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to an acute hospital on 5/24/20 after a fall hitting the back of her head requiring staples for laceration to the scalp and injury to her right foot. X-ray was negative for fractures. She had swelling and redness and was treated with antibiotics for possible cellulitis. She had a recent stroke in January 2020 with gait abnormality as a residual. She is otherwise stable medically. All her labs are normal and head CT showed no new events. A head injury is added to the diagnosis with no neurological exam to identify deficits. Based on review of the available records, the patient does not meet criteria for IRF admission. The patient was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. The patient may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour next test strips 200/30 days (A4253).
You asked the Plan to pre-approve Contour next test strips 200/30 days. You say that the requested items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that more than 300 test strips and more than 300 lancets every 3 months are covered if specific criteria is 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 Contour next test strips 200/30 days. Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee is noted to be a type II diabetic, who uses an insulin pump and is ordered to test her blood glucose four times a day. There is no evidence that the enrollee needs to test her blood glucose more often than that (i.e. uncontrolled, wide blood glucose (BG) variation, frequent hypoglycemia, ongoing medication changes). The health plan has approved coverage for 450strips/90days, which appears to meet the enrollee's current needs and treatment plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour next test strips 200/30 days have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour next test strips 200/30 days (A4253).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a single level spinal fusion.
You asked the Plan to pre-approve the spinal fusion. You say that you would like reconsideration because you have experienced back pain for 10 years and have exhausted all conservative treatments. The Plan denied your request. The Plan says this service 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 spinal fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature would not support fusion at this time. There is no clear evidence of vacuum phenomenon documented on radiographic study reports or evidence of advanced degenerative disc disease at any level. There is no evidence of neurologic deficit or spinal instability. There is no clear evidence of (comprehensive recent and detailed) conservative treatment, including medications or injection therapy. 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 spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a single level spinal fusion.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve routine transportation trips. The Plan denied your request. The Plan says that this is not covered by your Plan.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation trips have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair for the enrollee.
You asked the Plan to pre-approve a shower chair. You say that the enrollee suffers from low back pain, difficulty walking and standing. The Plan denied your request. The Plan says that this is not covered.
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-approve a shower chair for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.
You asked the Plan to pre-approve physical therapy. You say that it is crucial that the enrollee receive this treatment without interruption. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee may continue to improve through the use of a home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive skilled physical therapy and does not require ongoing skilled services for her level of function and condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee should be versed in a home exercise program at this point. The requested services are not part of a maintenance 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot surgery services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON foot surgery. You say that the enrollee's condition requires this surgery. The Plan denied your request. The Plan says there are many in-network providers able to perform the surgery needed in this case.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the foot surgery services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 29, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the submitted documentation did not contain a physician order or laboratory Results from the billing provider.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 pay for the lab services provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on February 20, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99213 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only ifa clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99213 and 01480. Code 99213 is a column II code with a modifier indicator of 1 when billed with column I code 01480. Code 99283 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay for the office visit rendered on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 5, 2018.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on December 5, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on November 12, 2019.

You asked the Plan to waive the copayment for the lumbar injection. You say that you do not believe that the lumbar injection meets the criteria for an outpatient surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for Medicare-covered surgery or other services provided to you at an in-network ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $395 copayment for the lumbar injection.

You have been asked to pay a $300.60 copayment for the lumbar injection. The lumbar injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows that the lumbar injection is considered a surgical procedure.

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 lumbar injection provided on November 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 30 to 74 minutes of critical care services (99291) provided on November 29, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed service.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the record does not include the time spent rendering critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the first 30 to 74 minutes of critical care services (99291) provided on November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an IRF admission.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 enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. An IRF admission is not medically necessary based on her current functional status.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from October 9, 2019, to October 31, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider from October 9, 2019, to October 31, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous transcatheter closure of the left atrial appendage (heart repair surgery).
You asked the Plan to pre-approve heart repair surgery. You say that you are losing blood and severely anemic, so you need this procedure. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this procedure is not medically necessary.
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 heart repair surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have presented with uncontrolled atrial fibrillation which has failed cardioversion and ablation treatments. You have a history of gastrointestinal (GI) bleeding. This clinical scenario suggests that ongoing anticoagulation is higher risk for you and is currently worsening your GI bleeding. Considering this intolerance or inappropriateness of ongoing anticoagulation therapy and ineffectiveness of ablation and cardioversion, this proposed procedure which lowers stroke risk is 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 heart repair surgery have been met. Therefore, we decided that the Plan has to pre-approve percutaneous transcatheter closure of the left atrial appendage (heart repair surgery).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 4, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on February 4, 2020.