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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 in the Medicare rules section. 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 pain and infection in the foot. A partial amputation of the foot was performed. 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery
only, through separate skin or fascial incision (CPT code 20939), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal
fusion surgery have NOT been demonstrated in the peer-reviewed literature.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found bone marrow aspirate remains experimental in cases of spinal fusion surgery. More research is
needed to show safety and efficacy.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or
fascial incision (CPT code 20939), for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cervical epidural steroid injection (62321).
You asked the Plan to pre-approve the steroid injection. You say that the enrollee is in pain and the service has not been rendered yet. The Plan denied your request. The Plan says that the level of relieve received from the previous epidural was not documented. This does not meet the criteria for a repeat epidural injection.
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 steroid injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee's MRI demonstrated C3-C7 degenerative changes with multilevel foraminal narrowing and moderate central stenosis at C3-4 and C506. She has radiation of pain to both shoulders. She has previously had therapy and failed conservative treatment. She was originally approved for a cervical epidural injection but this was not performed. The enrollee now has a pacemaker precluding repeat MRI. The enrollee was previously approved for the requested procedure. The plan was unaware this service was not provided. She as subsequently had a pacemaker so a repeat MRI cannot be performed. The requested procedure 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 the steroid injection have been met. Therefore, we decided that the Plan has to pre-approve cervical epidural steroid injection (62321).
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 pre-approve genetic testing for Lynch Syndrome (81317, 81292, 81295, 81298).

You asked the Plan to pre-approve the genetic testing. You say that you have a strong family history of cancer and therefore the genetic testing is medically necessary. The Plan denied your request. The Plan says this test is not a covered benefit unless you have a current or past cancer diagnosis.

The Plan must follow Medicare rules. Medicare rules say that molecular testing for Lynch Syndrome to identify carrier status, or family studies, are not a covered benefit.

We looked at the file and Medicare rules. The documentation provided does show a familial history of cancer, however, Medicare rules require that the enrollee has a history of cancer or current cancer diagnosis (referred to as a "personal history") for this test to be covered. The documentation provided does not show that you have a personal history of cancer.

Without a personal history of cancer, this testing is considered a screening test. Screening for Lynch Syndrome is not among the screening tests that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for Lynch Syndrome (81317, 81292, 81295, 81298). Please note that this decision does not restrict you from obtaining the test if you choose, it only affirms that it would not be eligible for coverage or payment by your Medicare health plan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until December 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on April 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is willing and capable of participating in
therapy three hours per day. The Plan denied your request. The Plan says the enrollee does not have complex
rehab needs that can only be met at an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for diabetic foot ulcer and had a below the knee amputation.
His medical problems are stable. There are no complex nursing needs. While the medical record supports a
need for physical and occupational therapy, there is no documented need for intensive rehabilitation 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound.

You asked the Plan to waive the copayment for the ultrasound. You say that the claim was for a mammogram which is covered at $0. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $115 copayment for each Medicare-covered radiological diagnostic service from an in-network provider.

You have been asked to pay $107.10, which is less than the standard $115 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The records show you were not charged for the mammogram, only the ultrasound. 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 ultrasound.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.

You asked the Plan to pre-approve Tadalafil. The Plan denied your request. The Plan says this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil.

Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not require transfer to LTACH.

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. Long term acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. You are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in-bathtub.

You asked the Plan to pre-approve a walk-in-bathtub. You say that you need this because of your osteoarthritis and hypothyroidism. The Plan denied your request. The Plan says this item is not medical in nature.

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 walk-in-bathtub.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care.

You asked the Plan to waive the copayment for SNF care. You say that you feel that the copayment should be covered. 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 a $0 copay per day for days 1 through 20 and a $172 copay per day for days 21 through 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted a total of 45 days, resulting in a total copayment amount of $4,300.

You have been asked to pay a $0 copay per day for days 1 through 20 and a $172 copay per day for days 21 through 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to approve continued physical therapy (PT) sessions.
You asked the Plan to 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. 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 approve these services. 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 records show that you have left shoulder and knee pain and have had 50 PT visits since July 20, 2020. The requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive prior therapy extensive prior therapy and the records do not show significant deficits on physical exam of the knees. You do not require 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 services are not part of a maintenance program and you do not need the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 approve continued physical therapy (PT) sessions.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer device is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over standard lumbar laminectomy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of this device 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 the interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cervical medial branch blocks (MBBs).
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic neck pain and has had physical therapy and is doing a home exercise program. The physical exam shows pain on range of motion, flexion and extension, and Spurling test. He has failed conservative therapy, has magnetic resonance imaging (MRI) documented facet disease, and the physical exam confirms facet-related disease. The MBBs are therefore reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve cervical medial branch blocks (MBBs).
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for therapeutic procedures (97112) and manual therapy techniques (97140).

You asked the Plan to pay for the therapeutic procedures and manual therapy techniques. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says that the documentation submitted does not indicate that a total of 15 minutes was spent providing this therapy service on this date of 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. 

We find that CPT codes 97112, and 97140 are supported in the record. Specifically, the records submitted clearly indicate the amount of time spent rendering the billed services. The documentation shows that a total of 15 minutes was spent rendering therapeutic procedures and 13 minutes were spent rending manual therapy. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures and manual therapy techniques have been met. Therefore, we decided that the Plan has to pay for therapeutic procedures (97112) and manual therapy techniques (97140).

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 two extractions, erupted tooth or exposed root (elevation and/or forceps removal (D7140).

You asked the Plan to pay for the two tooth extractions. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the service is not covered under your dental benefit.

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 two extractions, erupted tooth or exposed root (elevation and/or forceps removal (D7140).

Your complaint about being dissatisfied with the coverage provided by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.