Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit you had with a cardiologist and the electrocardiogram (ECG) you had on February 11, 2021.
You asked the Plan to waive the copayments for the office visit and the ECG. You say that you have never had to pay a copayment for this service in the past. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that you were appropriately charged the specialist office visit copayment as well as the copayment for the ECG. The Plan also stated that because the allowed amount for the ECG ($12.99) is less than your copayment for this service, you are responsible for this full allowed amount. Finally, the Plan says that when you had this service in 2020, you were also assessed cost sharing for it.
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 $30
copayment for visits with a specialist and a $20 copayment for each non-radiological diagnostic service. You have been asked to pay a $30 copayment for the office visit and a $20 copayment for the ECG. The office visit falls within the visits with a specialist benefit category and the ECG falls within the non-radiological diagnostic services benefit category. This means that you have been asked to pay the correct amounts 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 the office visit you had with a cardiologist and the electrocardiogram (ECG) you had on February 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ellipta (J3535).
You asked the Plan to pre-approve the Ellipta. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 the Ellipta (J3535).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Theraskin (CPT code Q4121), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee is diabetic with chronic ulcerations on the right and heel. You state there has been significant successful closure with Theraskin. The Plan denied your request. The Plan says clinical studies have not proven TheraSkin to be an effective treatment for the enrollee's foot wound.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer found the review does not indicates that the enrollee's diabetes is controlled, has followed all recommendations for other treatments, there is no infection in the ulcer or the bone beneath it, has good blood flow to the area. In addition, clinical studies have not proven TheraSkin to be an effective treatment for the foot wound. There are other treatments available. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve Theraskin (CPT code Q4121), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation of acute psychotic symptoms.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you do not have dangerousness to self or others, auditory or visual hallucinations, delusions and are not showing any behavioral issues. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. Our physician reviewer found your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rezum procedure (minimally invasive transurethral water vapor therapy for benign prostatic enlargement which uses thermal energy for treatment) (CPT code 53854), for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the enrollee has benign prostatic hyperplasia (an overgrowth of prostate tissue that pushes against the urethra and the bladder, blocking the flow of urine). The Plan denied your request. The Plan says the criteria are not met because submitted clinical notes state the enrollee's prostate volume is 20cc's and there is no indication that the enrollee is a poor candidate for other surgical interventions due to underlying disease.
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 procedure. Our physician reviewer found the submitted clinical notes state enrollee's prostate volume is 20cc and there is no indication that enrollee is a poor candidate for other surgical interventions due to underlying disease. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Rezum procedure (minimally invasive transurethral water vapor therapy for benign prostatic enlargement which uses thermal energy for treatment) (CPT code 53854), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left reverse total shoulder arthroplasty for the enrollee.
You asked the Plan to pre-approve these services. You say that the patient has limited external rotation and the magnetic resonance imaging (MRI) report was under read as she has significant tearing. The Plan denied your request. The Plan says that criteria for this service is not 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is limited published, large-scale, long-term peer-reviewed literature that shows a reverse total shoulder arthroplasty to be an effective and/or safe treatment in the absence of cuff tear arthropathy and/or irreparable rotator cuff tears. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative (medical and/or surgical) care measures. The enrollee is noted to have had 3 weeks of physical therapy and Tylenol. It is not clear as to when this occurred, and any progress made. The considered type of surgical intervention is not typically supported without noting a detailed trial and failure of recent and reasonable less invasive treatments. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a left reverse total shoulder arthroplasty for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from August 7, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from August 7, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested treatment 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 a Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that imaging has demonstrated mild spinal stenosis at L3-L4 and
severe spinal stenosis at L4-L5, the levels requested for treatment. The elements of the coverage criteria 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Surgery
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 the record indicates that the enrollee has chronic low back pain and spinal stenosis with neurogenic claudication. The record indicates that imaging from January 2020 demonstrated multilevel disease. No recent imaging has been performed. The case file does not indicate that the enrollee has relief in flexion. The record indicates that the enrollee will undergo rhizotomy prior to the decision to perform the requested procedure. The elements of the coverage criteria 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic footwear (CPT code L3221).
You asked the Plan to pre-approve the orthopedic footwear. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the orthotics will not be attached to a brace and you do not have diabetes foot disease.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the orthopedic footwear (CPT code L3221).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the knee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary to help reduce knee pain. The Plan denied your request. The Plan says this is considered 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is considered 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for injections provided on December 15, 2020 and January 14, 2021.

You asked the Plan to waive the cost share for the injections. You say that the procedures were done in the physician's office therefore there should not be any cost share. The Plan denied your request. The Plan says you were charged the coinsurance and deductible correctly.

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 a $30 copayment for specialist office visit, and you have a $203 deductible for 2021 that was not met for the physician services. 

The item or service you asked the Plan to waive the cost share for falls within the benefit category Physician services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $30 copayment for specialist office visits, and you have a $203 deductible for 2021 that was not met for Physician services. This cost sharing is a contractual obligation that had not been met at the time the injections was received on January 14, 2021. Therefore, we decided that the Plan does not have to waive the cost share for injections provided on December 15, 2020 and January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on October 5, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The documentation does not contain evidence of an established relationship between the enrollee and the ordering physician. In addition, the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on October 5, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the second opinion and gastroplasty (43845).
You asked the Plan to pre-approve the second opinion and gastroplasty. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers available for this service.
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 the second opinion and gastroplasty (43845).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay
provided September 1, 2020 to September 30, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you were told that as long as the
enrollee was being provided therapy, that she would be covered with no out of pocket expense. The Plan
denied your request. The Plan says the claim was processed with correct copayment applied per the Evidence
of Coverage.
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 $0 per
day for days 1-20 and $178 per day for days 21-100 for skilled nursing facility (SNF) care.
You have been asked to pay $3,146.97 for the SNF stay. The SNF stay falls within the skilled nursing facility
(SNF) care benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility
(SNF) stay provided September 1, 2020 to September 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.