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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no identified problems that need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.
You asked the Plan to pre-approve these services. You say that you cannot go home. The Plan denied your request. The Plan says the services are not medically necessary.
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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on December 4, 2020 with complaints of left leg and thigh pain. You were evaluated in the emergency department (ED) and were found to have contractures in your legs. The records do not support a reasonable expectation that you will require at least two midnights of inpatient hospital 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital services.
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 you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 still requires acute hospital level of care services and is receiving
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are
not available at the acute care hospital where the enrollee is currently receiving care. There are no services
available at the LTACH that the enrollee requires that are not available at the health care setting being offered
by the health plan. 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-approveinsertion of an interspinous spacer device (Vertiflex procedure).You asked the Plan to pre-approveVertiflex procedure. You say that this procedure is needed and would reduce the enrollee's pain medication intake.The Plan denied your request.The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/investigational procedure and is not part of evidence-based algorithms.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflexprocedure).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve robotic-assisted bronchoscopy (RAB) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary to obtain a tissue
diagnosis. The Plan denied your request. The Plan says the lesion is not documented to be in a location not
amenable to transthoracic needle aspirate.
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 RAB is a new addition to fiberoptic bronchoscopy that may improve bronchoscopic access to lung
lesions, but so far, clear advantages have not been demonstrated in well-designed clinical trials. Trials are
currently underway. This component of the procedure is therefore considered investigational, and therefore not
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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve robotic-assisted bronchoscopy (RAB) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you would like approval for these services.
The Plan denied your request. The Plan says there are in-network providers available.
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
physical therapy to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for diagnostic mammograms provided on
April 6, 2020.
You asked the Plan to waive the copayments for diagnostic mammograms. You say that you should not owe
anything for cancer screenings. The Plan denied your request. The Plan says the claims were processed
correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $210
copayment for each diagnostic procedure and test.
The medical records show that you received diagnostic mammograms provided on April 6, 2020. Therefore,
you are responsible to pay $143.01, which is less than the $210 copayment.
You have been asked to pay $143.01 for diagnostic mammograms. Diagnostic mammograms fall within the
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayments for diagnostic mammograms provided on April 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveacute  IRF admission  and  services.You asked the  Plan to pre-approveIRF care. The  Plan  denied  your  request.  The  Plan  says the enrollee  does not meet  Medicare  guidelines  for  services  in  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  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 complexity  of  the enrollee's  nursing,  medical  and rehabilitation  needs does not require  an acute  hospital  inpatient  stay  with  an interdisciplinary  approach  to rehabilitation  care. Our reviewer found  that  the  enrollee  does not require  treatment  by multiple  therapies,  including  either  physical  therapy  or occupational  therapy,  and an intensive  rehabilitation  therapy  program.  The  medical  record supports  a need for physical  and occupational  therapy,  but  it  does not support  a need for an  intensive  rehabilitation  therapy program.  Our physician  reviewer  also  found  that  there  is not  a reasonable  expectation  that  this  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-approveacute  IRF admission  and  services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for myocardial perfusion imaging and
echocardiography provided on May 22, 2020.
You asked the Plan to waive the copayments for myocardial perfusion imaging and echocardiography. You say
that you disagree with the facility charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125
copayment for diagnostic radiology and a $25 copayment for non-radiological diagnostic procedures and tests.
You received myocardial perfusion imaging on May 22, 2020. Therefore, you are responsible to pay the $125
copayment.
You received echocardiography on May 22, 2020. Therefore, you are responsible to pay the $25 copayment.
The total amount you owe is: $150.
You have been asked to pay the total copayment amount of $150 for myocardial perfusion imaging and
echocardiography. Myocardial perfusion imaging and echocardiography fall within the outpatient diagnostic
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments
for myocardial perfusion imaging and echocardiography provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS).
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is 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 not medically necessary. Our physician reviewer found the enrollee has chronic low back pain.
He has not had a trial of intrathecal drug therapy or prior spine surgery. He has not had a surgical consultation.
There is no documented evidence-based indication for the SCS trial. The services are therefore not reasonable
or 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve a spinal cord stimulator (SCS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approvea spinal  cord stimulator  (SCS) trial.You asked the  Plan to pre-approvethese  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.  Medicare  rules  say  that  an SCS trial  is  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 not medically  necessary.  Our physician  reviewer  found  the  enrollee  has chronic  low  back pain and lumbar  radiculopathy.  She also  has  spinal  stenosis.  She does not have  an evidence-based  indication  for  the SCS trial.  The  requested  SCS is  therefore not  reasonable  or 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  not been  met.Therefore,  we decided  that  the  Plan  does not have to pre-approvea spinal  cord stimulator  (SCS) tr
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 21, 2020, by an OON provider.
You asked the Plan to pay for comprehensive medication services. You say that you were advised that the provider is contracted. The Plan denied your request. The Plan says rules for payment have not been met.
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 items/services at issue in this appeal. 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 for the medical services provided on April 21, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 10, 2020, by an OON provider.You asked the Plan to pay fora cardiac diagnostic test. You say that the enrollee's benefit package includes benefits for cardiac diagnostics.The Plan denied your request. The Plan says rules for payment have not been met.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 items/services at issue in this appeal. 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 forthe medical services provided on February 10, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen system.You asked the Plan to pre-approvea portable oxygen system. You say that you only have about three days' worth of oxygen left.The Plan denied your request. The Plan says a portable oxygen system is not considered reasonable and necessary.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  To qualify for home oxygen, the patient must meet one of the following blood gas levels:1. Arterial PO2 at orbelow 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidenceof dependent edema, pulmonary hypertension, or erythrocythemia.For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.We asked our physician reviewerto 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 a portable oxygen system. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records do not include oxygenation during exercise/activity.  Only overnight oximetry from 2015 is provided, and this does not meet Medicare criteria for group I patients.  The diagnosis is COPD, but there is no evidence for heart failure, cor pulmonale, or erythrocythemia to qualify as group II.  Because the overnight oximetry shows hypoxemia for less than 5 min, home supplemental oxygen, including portable oxygen, is not 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 a portable oxygen system have not been met.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye exam provided on August 31, 2020, by an
out of network (OON) provider.
You asked the Plan to pay for the medical eye exam. You say that you would like this claim processed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the
facility or the provider; therefore, payment has been correctly denied.
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 items/services at issue in this appeal. 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 for the medical eye exam provided on August 31,
2020, by an out of network (OON) provider.