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

We decided that the Plan has to pre-approve ambulance transportation.
You asked the Plan to pre-approve ambulance transportation. You say that you cannot balance. The Plan denied your request. The Plan says that a physician's office is not an indicated destination for ambulance transportation.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance transportation. Our physician reviewer found that round trip ambulance transportation from home to the doctor's office has been requested. You are not supposed to bear weight because you have pain because both of her arms were fractured, and you have a dislocated shoulder. Your balance is off, and you are on pain medication and a muscle relaxant. The review indicates that your presenting symptoms met prudent layperson criteria for emergency care. Therefore, the requested transportation services are 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 ambulance transportation have been met. Therefore, we decided that the Plan has to pre-approve ambulance transportation.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crestor (J8499).

You asked the Plan to pre-approve Crestor. You say that you have taken this medication for several years, and it works extremely well. 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 Crestor (J8499).

Benefits for Crestor 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 you are appealing this denial. 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 you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide two one-way trips that exceed 50 miles.

You asked the Plan to provide longer transportation trips. You say that this transportation is necessary for you
to see your specialist. The Plan denied your request. The Plan says only routine transportation trips up to 50
miles one-way are eligible for coverage.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation services for up to 36 one-way trips per calendar year. Each oneway
trip must not exceed 50 miles of driving distance. You are responsible for any costs over the trip limit.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to provide two one-way trips that exceed 50 miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says you do not require complex nursing care, or frequent medical practitioner oversight for assessment and monitoring.
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 have a past medical history of end stage renal disease, diabetes, and a hospital admission for sepsis in April 2021.
You are living at home with increasing weakness. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-one (J7325).
You asked the Plan to pre-approve Synvisc-one. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement device.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-one. Our reviewer says that Synvisc-one (J7325) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires these be trialed first. Our reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer also found that without the support of the documentation, Synvisc-One is not approved, as step criteria have not been 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 Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-one (J7325).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays (73110, 73090) provided on July 14, 2020.

You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says these services were already paid.

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 73110 and 73090 are not supported in the medical record. Specifically, the records show that only one unit of each CPT code was performed on the date of service in question. The Plan has already paid for one unit of each CPT code. Additional units are not supported, and therefore not payable. Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the x-rays (73110, 73090) provided on July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the Centers for Medicare & Medicaid Services (CMS) defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the current ACH until such time no acute services are required. Our physician reviewer also found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.

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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SurFactor or NuDyn.

You asked the Plan to pre-approve SurFactor or NuDyn. 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 Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) is covered under specific circumstances. 

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 SurFactor or NuDyn. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that you do not meet the coverage criteria detailed in the NCD. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SurFactor or NuDyn have not been met. Therefore, we decided that the Plan does not have to pre-approve SurFactor or NuDyn.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice setting (G0151).

You asked the Plan to pre-approve the services performed by a qualified physical therapist. You say that you are homebound and wheelchair bound, and would like to appeal this service. The Plan denied your request. The Plan says documentation was not provided from a doctor showing that you require skilled nursing, physical therapy, or occupational therapy.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 performed by a qualified physical therapist. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled rehab services to provide treatment that is medically necessary. You do not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that there is no indication that you have had a recent shoulder injury or worsening symptoms that is impairing your function. 

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 performed by a qualified physical therapist have not been met. Therefore, we decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice setting (G0151).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the fillings. We decided that the Plan does not have to pay for the core build up.

You asked the Plan to pay for the fillings and core build up. You say that these services should be covered. You say that you have never had periodontal disease. You also say that you feel you have been misled by your dental office. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that the fillings for teeth # 8 and 9 are not covered as the coding is not supported.

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. The Plan covers dental services when the services are medically necessary and reasonable.

We decided that the Plan has to pay for the fillings.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fillings have been met. Specifically, the Evidence of Coverage clearly states that 2 fillings are covered per calendar year. Therefore, we decided that the Plan has to pay for the fillings.

We also decided that the Plan does not have to pay for the core build up.

Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up provided on September 28, 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 for the lab services provided on August 27, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 29, 2021 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. You say the code billed does not require prior authorization. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 service 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 physician services provided to the enrollee on January 29, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on December 28, 2020 and billed under codes 87486, 87496,87498, 87541, 87581, 87640, 87798 and 87532.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says while code U0003 was paid, the place of service (POS) code on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
The submitted claim indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
Also, the laboratory results submitted indicate the specimen was collected on December 28, 2020 and received by the lab on December 29, 2020. Of note, the enrollee resides in Floridan and the billing laboratory is located in Georgia therefore, the codes or services billed are inconsistent. The Plan states multiple attempts were made to obtain additional information from the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, codes 87486, 87496,87498, 87541, 87581, 87640, 87798 and 87532 cannot be paid as billed due to an issue with the POS code reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on December 28, 2020 and billed under codes 87486, 87496,87498, 87541, 87581, 87640, 87798 and 87532 shall remain unchanged.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery (arthrodesis, autograft, allograft) for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary for the enrollee's central and foraminal stenosis. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record indicates that the enrollee has severe L1-L2, L2-L3, and L3-L$ disc degeneration and spondylolisthesis resulting in central and foraminal stenosis. Decompression and fusion is requested. The plan has approved the decompression but upheld the fusion denial. Coverage for CPT code 20930 is bundled and not separately payable. The elements of the coverage rule are not satisfied. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spine surgery (arthrodesis, autograft, allograft) for the enrollee.