Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve iron infusion.You asked the Plan to pre-approve iron infusion. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are 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 iron infusion. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of iron deficiency anemia due to chronic blood loss. There is documented progression in iron deficiency despite oral iron supplementation, with hemoglobin decrease from 13.1 to 12.0 and iron decrease from 77 to 45. The enrollee has a diagnosis, condition, and/or symptoms that meets the Medicare criteria for coverage of iron infusion. Iron infusion is considered the standard of care for the treatment of this enrollee's condition. The enrollee meets criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of iron infusion have been met.Therefore, we decided that the Plan has to pre-approveiron infusion.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a caseagain 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: Unfavorable

We decided that the Plan does not have to pay for the medical services provided in a chiropractor office on
November 11, 2019.
You asked the Plan to pay for the services provided. You say that the enrollee is making improvement from the
procedures. The Plan denied your request. The Plan says they only cover manual manipulation of the spine to
correct subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the medical services provided in a chiropractor office on November 11,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on February 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for mental health services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 mental health services provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July
2, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians
custom profile. The Plan denied your request. The Plan says the documentation did not include a valid
physician order or medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing
why the lab services provided were medically necessary.
We find that the drug testing is not supported in the medical record. In this case, there is no evidence that
shows the test was individualized to identify specific non-prescribed medications or illicit substances. The
records provided do not document concerns based on clinical review and judgement. Therefore, we decided
that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) and the office visit (99212) provided January 31, 2020 to February 19, 2020.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.You are nota 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 forthe chiropractic manipulative treatment (98940) and the office visit (99212) provided January 31, 2020 to February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332), core buildup, including any pins when required (D2950), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) and crown - porcelain fused to high noble metal (D2750) provided on October 17, 2018 and October 26, 2018.
You asked the Plan to pay for the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. The Plan states that you did not elect to enroll in an optional supplemental package.
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. These services/dental codes are not listed in your EOC as covered benefits; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior (D2332), core buildup, including any pins when required (D2950), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335) and crown - porcelain fused to high noble metal (D2750) provided on October 17, 2018 and October 26, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig provided to the enrollee on January 24, 2020.
You asked the Plan to pay for the wig. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig provided to the enrollee on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) and shoulder elbow wrist hand orthosis  (L3960) provided to the enrollee on February 4, 2020.You asked the Plan to pay forthe orthoses. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) and shoulder elbow wrist hand orthosis  (L3960) provided to the enrollee on February 4, 2020.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that he requires this therapy on an intensive rehabilitation therapy program provided in an IRF.We looked at thisphysician'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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services and injections provided on November 13, 2019.
You asked the Plan to pay for therapeutic services and injections. You say that these services were medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services were not medically necessary or not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic services and injections provided on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from November 23, 2019 to February 7, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that that all treatments and therapy could have been administered on an outpatient basis and did not warrant inpatient hospitalization.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from November 23, 2019 to February 7, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on September 6, 2019  by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forlab work provided on September 6, 2019  by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immune globulin infusion (J1569).
You asked the Plan to pre-approve immune globulin infusion. 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 follows Medicare rules. Medicare rules say that the use of IVIg is covered when certain 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 immune globulin infusion. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case there was no evidence that the enrollee had a rapidly progressive form of CIDP. Nor was there documentation that any other therapies had been trialed or were contraindicated. Consequently, the request would not meet the requirements for coverage at this time based on the records provided for review. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of immune globulin infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve immune globulin infusion (J1569).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac joint injections (27096).You asked the Plan to pre-approvesacroiliac joint injections. You say that the services are necessary.The Plandenied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 sacroiliac joint injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, it is unclear if your pain pattern is due to sacroiliac (SI) joint dysfunction. There was no documentation of positive exams with regard to the sacroiliac joint injections (SIJ). In addition, there is no documentation indicating you have failed at least 4-6 weeks of aggressive conservative therapy including, physical therapy (PT), home exercise, and medication management. Medical necessity for the bilateral SIJ injections has not been established. The requested SIJ injections are not medically reasonable or 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 sacroiliac joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac joint injections (27096).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physical therapy visit provided on
January 29, 2020.
You asked the Plan to waive the deductible for the physical therapy visit. You say that you were not aware this
visit was for physical therapy. You say you thought the appointment was for a diagnosis of the imaging. 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. Your
contract with the Plan says that there is $245 deductible that applies towards the physical therapy visit.
The physical therapy visit you asked the Plan to waive the deductible for falls within the "Outpatient
rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is $245 deductible that applies towards the physical therapy visit. The medical record shows
you were seen for a physical therapy visit.
This cost sharing is a contractual obligation that had not been met at the time the physical therapy visit was
received on January 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the
physical therapy visit provided on January 29, 2020.
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have no documented medical or nursing needs that require admission to inpatient care. You do not require treatment by multiple therapies, including physical therapy or occupational therapy, and 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. 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.