Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) sessions
You asked the Plan to pre-approve 10 additional PT sessions. You say that the enrollee needs these services. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 10 additional PT sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient had had extensive prior therapy for this condition and trained in a home exercise program. Her remaining knee deficits and functional level do not require the unique skills of a professional therapist to safely and effectively provide treatment, and services do not need to only be safely and performed by a therapist, or for physical therapy and occupational therapy be by or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) sessions
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services and x-ray.
You asked the Plan to pre-approve the physician's services and x-ray. You say that this physician performed your shoulder surgery and you have been having follow up appointments every three months and you would like your last follow up visit with him. The Plan denied your request. The Plan says you must receive care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve the  physician's services and an x-ray.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and stay to beprovided by a SNF.You asked the Plan to pre-approveSNF admission and stay. You say that the enrollee needs wound care done at a facility because of increased weakness and decreased mobility.The Plan denied your request. The Plan says the enrollee does not need more skilled therapy services, complicated wound care, care for complex medical needs, or antibiotics through her veins.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factorslisted above 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 admission and stay. Our reviewer says that the enrollee doesnot meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 admission and stay have not been met.Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approveSNF admission and stay to be provided by a SNF.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for services rendered by an out-of-network provider.
You asked the Plan to pre-approve the in-network exception. You say that you have been seeing this provider for 20 years and they have just recently become out-of-network. The Plan denied your request. The Plan says there are no network inadequacies seen so out-of-network benefits will be used to see this provider.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the in-network exception have not been met. Specifically, the record indicates that there are network providers available so you will be responsible for out-of-network cost sharing amounts as indicated per the EOC. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for services rendered by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Arm (73218).You asked the Plan to pre-approvethe MRI. You saythat the MRI is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the enrollee fails to meet the clinical criteria guidelines as she has had no documented physical therapy for 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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Arm (73218).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 16, 2019 by an out of network (OON) provider. You asked the Plan to pay for the office visit (99213). You say that you were not aware that you were out-of-network because the member presented incorrect insurance information. The Plan denied your request. The Plan says the member is enrolled in an HMO plan with no out-of-network benefits. 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 September 16, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 10, 2019. You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses were not 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 pay for the knee orthoses (L1851) and suspension sleeves (L2397). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer found the enrollee's chief complaint was knee pain, in addition to back and shoulder pain. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthoses (L1851) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses & suspension sleeves provided on August 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron injection services.
You asked the Plan to pre-approve the Lupron injection services. You say that the clinical information provided supports the need for the enrollee to continue receiving Lupron injections every 3 months. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. The Plan says that short-term androgen deprivation therapy (Lupron) is only supported for patients with intermediate risk prostate cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Lupron injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has been diagnosed with prostate adenoca. Lupron is not FDA-approved for the enrollee's diagnosis. The use of Lupron is not supported by one of the major drug compendia or clinical research that appears in a CMS-approved medical journal. 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 Lupron injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Lupron injection services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for adjustment and management of vascular access device provided on October 11, 2019 by an out of network (OON) provider. You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 adjustment and management of vascular access device provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a gallbladder removal (47600) provided on February 3, 2019 by an out of network (OON) provider. You asked the Plan to pay for a gallbladder removal. You say that this service should be covered. The Plan denied your request. The Plan says this service was not authorized. 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 a gallbladder removal (47600) provided on February 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that it would seem that if the hospital is considered an authorized provider, then any service rendered by the house provider would also be included in that authorization. The Plan denied your request. The Plan says the rendering provider is out-of-network. The Plan says that no prior authorization was obtained for 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 for an office visit provided on April 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on October 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that you performed the lab work that was requested by the physician. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that additional information was requested multiple times with no reply.
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 outpatient lab work provided on October 1, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148) and Knee (73721). You asked the Plan to pre-approve the MRI's. You say that the MRI's are medically necessary. The Plan denied
your request. The Plan says rules for coverage have not been met. The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI's. Our reviewer says that the MRI's are not medically necessary. Our physician reviewer found the records show history of injections every 4 months which seem to help the patient with her pain and she is due for another injection. Medications and a trial of physical therapy should be performed before additional imaging is 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 MRI's have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148) and Knee (73721).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 26, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 3,
2019 to October 2, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from September 3, 2019 to October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hand surgery provided on June 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for hand surgery. You say that your wife needed this surgery. You say that she could not wait. The Plan denied your request. The Plan says the enrollee could have safely waited to receive care on July 5, 2019
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 hand surgery provided on June 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home services provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for rest home 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 for 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 for rest home services provided on December 11, 2019 by an out of network (OON) provider.