Persius/hicric huggingface dataset:
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 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 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the limited documentation provided, in the absence of therapy records, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87631) provided December 11, 2020.
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan denied your request. The Plan says this is not a covered test.
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. The testing performed tested for more than 6 pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87631) provided December 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.
You asked the Plan to pre-approve Xgeva. You say that the requested Xgeva is medically necessary. The Plan
denied your request. The Plan says the enrollee has not tried and failed intravenous pamidronate or zoledronic
acid first.
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 Xgeva. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the review indicates that the
enrollee is with a history of multiple myeloma. Her provider has requested Xgeva. The Plan requires a trial of
intravenous pamidronate or zoledronic acid first before they will approve the requested drug. In this case, the
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the
Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to
pre-approve Xgeva.
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 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 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary.
The Plan denied your request. The Plan says this is not a covered service.
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 pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeated facet join injections.
You asked the Plan to pre-approve repeated facet join injections. You say that these injections are medically necessary. The Plan denied your request. The Plan says the documentation does not support 50% relief of pain for at least 3 months nor why this member is not a candidate for radiofrequency ablation.
The Plan follows Medicare rules. Medicare rules say that the minimum interval between therapeutic facet injections is 3 months. 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 repeated facet join injections. Our reviewer says that the requested injections are not medically reasonable and necessary. Our physician reviewer found you are a 73-year-old woman who had therapeutic intra-articular facet joint injections bilaterally at L3-L4, L4-L5, and L5-S1 on April 21, 2021, and had 2 days of pain relief. The request exceeds the LCD utilization which states that the minimal interval between therapeutic facet injections is 3 months. 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 repeated facet join injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeated facet join injections.
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 requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care 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 that the enrollee was admitted in March 2021 for stroke. The enrollee also had COVID-19 and required intubation. The enrollee tested positive for COVID-19 on May 11, 2021, and is still intubated. The enrollee is receiving acute care services and these services have not been denied. The record does not indicate that the LTACH would provide services the enrollee requires but is not receiving at the current facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay following surgery.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is an 84-year-old man who is scheduled for shoulder arthroplasty. In this case, the record does not indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights before the elective procedure. A decision can be made after a period of observation. The elements of the coverage rule are not satisfied. The requested service is not recommended.

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 not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital admission for a shoulder arthroplasty.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the separate request for the inpatient hospital admission remains denied.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case, the medical record does not indicate that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee can be placed in observation to determine whether admission is necessary. 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission for a shoulder arthroplasty.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to waive the deductible for a closed fracture treatment. We decided that the Plan does not have to waive the deductible for an X-ray.
You asked the Plan to waive the deductible for a closed fracture treatment and an X-ray. You say that you paid the $35 specialist copayment and disagree with the additional charges. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to waive the deductible for a closed fracture treatment in the amount of $245.31.
The Plan contract says that enrollees must pay a $35 copayment for specialist services. Specialist services include surgery services.
The record shows that you received a closed fracture treatment on September 23, 2020. A closed fracture treatment is considered a surgical procedure. Because services were provided by a specialist, you are only subject to the $35 copayment for specialist services.
The Plan says that you must pay deductible charges of $245.31 for a closed fracture treatment. However, you cannot be asked to pay more than a $35 copayment for specialist services. Therefore, we decided that the Plan has to waive the deductible for a closed fracture treatment in the amount of $245.31.
We also decided that the Plan does not have to waive the deductible for an X-ray in the amount of $31.51.
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 $750 deductible for an X-ray. The record shows that you had not met the $750 deductible amount prior to receiving the X-ray. Therefore, we decided that the Plan does not have to waive the deductible amount of $31.51 for an X-ray.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve genicular RFA. You say that you are appealing this denial. The Plan denied
your request. The Plan says the denial of authorization for this service is correct, because studies have not
shown that this treatment is beneficial.
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 genicular RFA. Our reviewer says that
the requested items/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.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) provided on January 4, 2021 by an out-of-network provider.

You asked the Plan to pay for the hearing aids. You say that you were told you could be reimbursed if you submitted the form after services. The Plan denied your request. The Plan says out-of-network services and items are only covered in limited circumstances. The requested hearing aids were provided out of network and were not urgent or pre-approved.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only they are provided in-network. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) provided on January 4, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87631) provided December 11, 2020.

You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan
denied your request. The Plan says this is not a covered test.

The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or
more pathogens are non-covered.

We looked at the file and Medicare rules. The PCR testing performed included more than 6 pathogens. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (87631) provided December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the topical application of fluoride varnish (D1206) received December 29, 2020.
You asked the Plan to pay for the dental services (D0120, D1110, D1206). You say that you were told you would have a $0 copayment for up to two cleanings per year. The Plan denied your request. The Plan says you exhausted your $1,000 annual maximum benefit allowance prior to this date of service.
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 payment is in excess of that which is covered under this benefit. The Plan has a $1,000 annual maximum benefit allowance. You are responsible for any remaining charges after the $1,000 allowance is exhausted. The Plan has submitted evidence that you exhausted the benefit allowance prior to this date of service. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the topical application of fluoride varnish (D1206) received December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says in order for this product to be covered, there must be evidence of use of three or more
insulin shots per day.

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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the criteria for this monitor is not met with documented notes - specifically, it is not shown if you are
taking multiple shots of insulin, and how the dose adjustments are made. There are inconsistencies.

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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor.
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 there are no local skilled nursing
facilities able to manage enrollee's needs and therefore the requested LTACH services are necessary. The Plan
denied your request. The Plan says rules for LTACH care 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 that the enrollee was admitted for pneumonia and transferred to the current facility
for a higher level of care. The enrollee continues to receive acute care services for which coverage has not been
denied. The enrollee does not require services that they are not currently receiving that only an LTACH facility
could provide. 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral, complete series of radiographic images (D0210), cone beam CT capture and interpretation, view of both jaws, cranium (D0367), collection and prep of saliva sample for lab diagnostic testing (D0417) received November 24, 2020.

You asked the Plan to pay for the dental services. You say that the requested services were recommended by your primary care physician. The Plan denied your request. The Plan says the requested services are not covered under your supplemental dental benefit.

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 or are in excess of those covered under this benefit. The Plan does not cover services D0210, D0367, or D0417. Though the Plan covers oral evaluations, this service is limited to one procedure per plan year. The Plan states that you have exhausted this benefit prior to this date of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral, complete series of radiographic images (D0210), cone beam CT capture and interpretation, view of both jaws, cranium (D0367), collection and prep of saliva sample for lab diagnostic testing (D0417) received November 24, 2020.