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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer 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 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 Long term acute care hospitals (LTACHs) 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. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 device. 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 guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of 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 as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has high-grade/critical neural foraminal narrowing on the left at L5-S1, moderate to advanced on the right at L4-l5 and moderate on the right at L2-L3; high-grade spinal stenosis at L3-4, lateral recess narrowing at L3-4 and L2-3 and would not meet FDA indications. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of slight retrolisthesis of L1 on L2, L2 on L3, and L3 on L4 with no discussion of spinal instability on flexion/extension films. Detailed documentation is not evident regarding scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, the requested Vertiflex device is not medically reasonable or necessary for treatment of 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 10, 2019 to October 18, 2019.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment of DRG is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 480 is defined as HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MAJOR COMPLICATION OR COMORBIDITY (MCC) - MARKET SIZE, PREVALENCE, INCIDENCE, QUALITY OUTCOMES, TOP HOSPITALS & PHYSICIANS. 

In this case, you billed the services provided in this case with DRG 480. 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the records support that DRG 481 is correct. A review of the medical records submitted did not validate J96.21 as the diagnosis for this admission. The secondary diagnosis code is one of the determining elements for MS DRG assignment and payment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 480. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 10, 2019 to October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that the enrollee requires a referral to an expert specialist in pelvic neuromodulation. You say that this is a highly specialized field of urology and you have located a highly regarded expert in this field in Tampa who has a particularly broad experience and a high level of expertise in this subspecialty of urology. The Plan denied your request. The Plan says this provider is not part of the Plan's network. Urology services, including second opinions, are available through the Plan's contracted and designated providers.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the requested physician is an out-of-network provider and there are in-network providers who can provide the needed 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission and right total hip arthroplasty.

You asked the Plan to provide coverage for inpatient admission. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says inpatient admission criteria are not met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 provide coverage for inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found at issue is coverage for an inpatient admission. You have primary osteoarthritis of the hips with progressive bilateral hip pain. Your past medical history is notable for hypothyroidism, depression, and hyperlipidemia. A right total hip arthroplasty is planned. The records do not show that you have significant co-morbidities that would be expected to result in complications. It is not reasonable to expect that the necessary hospital care (including earlier ED and/or observation care) would span at least two midnights. Inpatient 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to provide coverage for inpatient admission and right total hip arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for drug delivery device irrigation provided on September 9, 2020.

You asked the Plan to waive the copayment for irrigation procedure. You say that you were charged less for this service in previous years. 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 $350 copayment for in-network irrigation procedure at an ambulatory surgical center. 

You have been asked to pay the allowed amount of $50.53, which is less than the $350 copayment for irrigation procedure. Irrigation procedure falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 drug delivery device irrigation provided on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and implant supported crown.

You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and implant supported crown. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and implant supported crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve air purifier (E1399).

You asked the Plan to pre-approve air purifier. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not primarily used for a medical purpose and a person in the absence of an illness can still find this useful.

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 air purifier (E1399).
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. 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 documentation does not support that 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 documentation does not support the enrollee requires at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 crowns, porcelain fused to high noble metal (D2750).

You asked the Plan to pre-approve the crowns. You say that the services should be covered. The Plan denied your request. The Plan says crowns, porcelain fused to high noble metal, are not a covered service.

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-approve 2 crowns, porcelain fused to high noble metal (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toilet seat safety frame (grab bar).

You asked the Plan to pre-approve a toilet seat safety frame. You say that you need this frame to keep yourself from falling. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar 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 toilet seat safety frame (grab bar).
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 the expectation is that this enrollee will require long-term acute care with a stay greater than 25 days. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiocardiography with doppler complete for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is reported as clinically stable with no symptoms of dyspnea or signs of congestive heart failure or valvular heart disease. He has some history of atypical chest pain in the past but the current review of systems reports no chest discomfort. He has no signs or symptoms of valvular heart disease on exam. His most recent echo 1.5 years ago showed no significant valvular disease and normal left ventricle function. Based on both the lack of new clinical symptoms or signs of cardiac disease, as well as the ACC/AHA appropriate use criteria, he has no current appropriate indication for repeat transthoracic echocardiography, especially given the relatively recent prior normal echocardiogam study. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiocardiography with doppler complete for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).

You asked the Plan to pre-approve the dental items. You say that lost her dentures while she was in the hospital. The Plan denied your request. The Plan says dentures are covered once every 5 calendar years, per patient, per arch. The Plan also says that the frequency limit has been reached.

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 frequency of 1 denture per patient, per arch, every 5 calendar years has been reached. The record shows that the Plan paid for a partial upper denture and a partial lower denture that you received on March 28, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services provided on February 7, 2020 by an out of network provider.

You asked the Plan to pay for the colonoscopy services. You say that your referral was still valid. The Plan denied your request. The Plan says you did not request prior authorization for the out of network 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 had network providers available who could have provided 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 colonoscopy services provided on February 7, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the walk-in bathtub.

You asked the Plan to pre-approve the walk-in bathtub. You say that you would like reconsideration because this bathtub is medically necessary. The Plan denied your request. The Plan says this would be considered a convenience item primarily hygienic in nature and thus not covered.

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 the walk-in bathtub.