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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee was transferred to Meadowviewbecause the unit is a hospital base unit and the enrollee is design to be there for 20 days. You say that you are trying to get the enrollee to a facility that will be able to treat her longer.The Plan denied your request. The Plan says there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care. The Plan says that, while the enrollee may benefit from therapy, it does not need to be provided daily in an inpatient facility.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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursingservices with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care or other SNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care and ventilator support, telemetry, intravenous antibiotics, close fluid balance, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where heis currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care providedon November 6, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 withthe Plan. The Plan did not pre-approve the servicesat 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 subsequent nursing facility care provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are available in-network.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 these services.Therefore, we decidedthat the Plan does not have to pre-approvemedical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam therapy.You asked the Plan to pre-approvethe proton beam therapy. You say that the records provided support the medical necessity of proton beam therapy.The Plan denied your request. The Plan says this type of treatment is not supported for the enrollee's cancer type.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the proton beam therapy. Our reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of intermediate risk adenocarcinoma of the prostate, T1c, and a Gleason score of 3+4. Photon and proton ERBT are effective, with similar biochemical control, and side-effect profiles. A clear benefit of proton beam therapy compared to standard therapy has not been demonstrated in medical literature. There is no clear evidence to support a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity.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 proton beam therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forfour testing to monitor the depth of muscle relaxation during surgery (CPT 95999) billed for date of service June 24,2019.You asked the Plan to pay forthe four testing to monitor the depth of muscle relaxation during surgery. You say that the provider was in-network and that the documentation provided supports that payment should be made for the service in dispute.The Plan denied your request. The Plan says the service in dispute is considered integral to the primary procedure, neurophysiology monitoring, and therefore is part of a bundled payment.The Plan must follow Medicare rules. Medicare rules say that a physician shall not unbundle services that are integral to a more comprehensive procedure.We looked at the file and Medicare rules. Train of four (ToF) monitoring is considered part of the overall intraoperative monitoring service, which, in this case, was billed as CPT 95941. ToF monitoring is not neuromuscular junction testing. ToF testing does not have its own charge code. The billing of CPT 95941 for ToF monitoring is not supported.Therefore, we decided that the Plan does not have to pay forfour testing to monitor the depth of muscle relaxation during surgery (CPT 95999) billed for date of service June 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe breast localization device placement procedure provided on October 23, 2019.You asked the Plan to waive the copayment forthe breast localization device placement procedure. You say that there was no operating room and this was not a surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the breast localization device placement procedure. The breast localization device placement procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows this procedure is considered a surgical procedure.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 forthe breast localization device placement procedure provided on October 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission.You asked the Plan to pre-approvea SNF admission. You say that an inpatient skilled nursing facility admission is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled nursing facility admission.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 pre-approve a SNF admission. Our reviewer says that you do not meet criteria for coverageof an inpatient skilled nursing facility admission. Our physician reviewer found that you do not require skilled nursing or skilled therapy services on a daily basis in a skilled nursing facility. Additionally, youdo not require the necessary services onan 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 a SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet injections (64490 and 64491).You asked the Plan to pre-approve the injections. You say that you would like reconsideration as you are in pain and live alone. The Plan denied your request. The Plan says the documentation submitted does not show evidence that you have had any prior diagnostic injections to diagnose facet mediated pain.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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the member has had diagnostic blocks.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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet injections (64490 and 64491).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery (63030).
You asked the Plan to pre-approve the spinal surgery. You say that the surgery is medically necessary for the
treatment of the member's condition. The Plan denied your request. The Plan says the record does not show the
results of x-rays of the lower back within the past 6 months.
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 spinal surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found more conservative measures, such as physical therapy are needed.
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 spinal surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve spinal surgery (63030).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says care can be safely received in other settings, such as skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period.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) for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 2.You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says the crown for tooth # 2 is not medically necessary.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 the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the documentation provided was not sufficient to determine the need for a crown for tooth # 2. A radiograph of tooth # 2 was not provided and the record did not address the structural integrity of the coronal aspect of tooth # 2. Therefore, the crown for tooth # 2 cannot be found to be medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met.Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 2.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a tertiary provider (99203).You asked the Plan to pre-approve the office visit. You say that you would like to remain under the care of this provider. The Plan denied your request. The Plan says the service is available within the network at a non-tertiary level of care.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 office visit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have any suspicious lesions and therefore can be followed by a community, in-network dermatologist.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 office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit with a tertiary provider (99203).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Juvederm filler.You asked the Plan to pre-approve Juvederm filler. You say that you would like reconsideration as this will help with your speech and feeding tube. The Plan denied your request. The Plan says that this service is cosmetic in nature.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Juvederm filler. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this service is part of your reconstructive therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Juvederm filler have been met. Therefore, we decided that the Plan has to pre-approve Juvederm filler. 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: Inpatient Hospital
Decision: Unfavorable

e decided that the Plan does not have to pre-approve LTACH services for enrollee.You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be on the ventilator for 21 daysThe Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has not tolerated ventilator weaning and appears to have a poor long-term prognosis. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 for enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thoracic MRI (72146).You asked the Plan to pre-approve the MRI. You say that you have the classic symptoms and nerve pain. The Plan denied your request. The Plan says the MRI is not medically necessary.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 documentation does not support pain in the thoracic back, there is no documented abnormal physical exam findings of the mid back, or a differential diagnosis Our physician reviewer found without the support of the documentation, medical necessity cannot be determined.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-approve a thoracic MRI (72146).