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 you are still having trouble swallowing and are under the Frazier protocol. You need intensive therapy in order to regain your strength. The Plan denied your request. The Plan says a patient with a subdural hematoma and neurological deficits may be a candidate for IRF care. However, the documentation does not indicate precisely what deficits the patient has in his right lower leg nor that the patient can currently tolerate the 3 hours a day of intensive 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 enrollee was admitted to the hospital on 1/23/2020 due to large pulmonary embolisms. He had thrombolysis and heparin drip was started. On 1/26 he was found to have RLE weakness and headache and found to have an acute subdural hematoma. The heparin was stopped, and he was transferred on 1/27/20 to another facility for further possible neurosurgical management. He was found to also have some hematomas in his flank, buttock and lower chest wall. An IVC filter was placed and his CT showed no increase in the subdural hematoma. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the documentation does not indicate that the patient can tolerate the intensity of a rehabilitation in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion Vertiflex device for the enrollee.
You asked the Plan to pre-approve a Superion Vertiflex device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression is only covered when the enrollee is enrolled in a clinical study. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of a Superion Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there is no documentation of medical complexity to support the need for an inpatient rehab physician three times a week.
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 physician reviewer found that the enrollee is walking with contact guard assist using a wheeled walker. The enrollee is doing well without radicular symptoms in the lower extremities. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on June 3, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on June 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) for the enrollee.
You asked the Plan to pre-approve Transthoracic Echocardiography (TTE). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that TTE is only covered for certain indications. 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 Transthoracic Echocardiography (TTE). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has been treated for neurocardiogenic syncope and has improved. The enrollee has had not inter-current cardiac symptoms since the echocardiogram done 7 months ago and no changes in exam. The enrollee's prior echo was essentially normal as well. Based on the above Medicare covered echo criteria, a single echocardiogram to rule out structural heart disease in the setting of syncope is indicated, but the Medicare guidelines specifically do not cover routine yearly followup in the absence of a change in symptoms or physical exam findings. An initial echocardiogram was indicated to assess for structural heart disease, but routine yearly (or in this case less than one year) followup, especially when the initial echo was essentially normal and in the absence of any clinical changes, is both not medically necessary and not covered by the CMS guidelines. Therefore, the enrollee does not meet criteria for the requested testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Transthoracic Echocardiography (TTE) have not been met. Therefore, we decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duloxetine Cap 60mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit.
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 Duloxetine Cap 60mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered to the enrollee on April 16, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee received DecisionDx-Melanoma testing for a diagnosis of malignant melanoma of other part of the trunk, approximately 0.5 millimeters. This test is considered experimental/investigational in nature. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend use of the testing outside of a clinical study. The testing was not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered to the enrollee on April 16, 2019.
The Plan references Local Coverage Determination (LCD) L37725 in their determination; however, this LCD does not provide coverage criteria for the DecisionDx-Melanoma testing and was not used in the determination.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on August 27, 2019.
You asked the Plan to waive the copayment for the physical therapy visit. You say that you should not be responsible for the copayment because the provider did not inform you of the $40 copayment. 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 $40 copayment for each physical, occupational, and/or speech/language therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" 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 physical therapy visit provided on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) a shoulder-hand-wrist
orthosis (L3960) provided to the enrollee on September 13, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on August 29, 2019.
You asked the Plan to waive the copayment for the physical therapy visit. You say that you should not be responsible for the copayment because the provider did not inform you of the $40 copayment. 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 $40 copayment for each physical, occupational, and/or speech/language therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" 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 physical therapy visit provided on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 26, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the laboratory services rendered to the enrollee on August 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's
care needs are custodial.
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 SNF services. Our physician reviewer
found that from a nursing perspective, the enrollee had stable vital signs, and was treated for a UTI with effect.
There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at standby
assist to supervision with functional mobility. Although there are identifiable skilled therapy service needs, the
enrollee does not require skilled nursing or skilled therapy services on a daily basis. The enrollee does not meet
severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 27, 2019 by the out of network provider.
You asked the Plan to pay for physician services. You say that you saw the patient at the facility. You say that you are requesting reconsideration for payment. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that prior authorization was not 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 physician services provided on September 27, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal manipulation services to be provided by an out of network (OON) chiropractor.
You asked the Plan to pre-approve the OON chiropractic services. You say that you believe that the enrollee should be allowed to continue with this provider even though you are OON. You feel that it would benefit the enrollee to only receive chiropractic care from this office. The Plan denied your request. The Plan says there are several network chiropractors within a reasonable distance of the enrollee's home who can provide this care. Three transitional visits have been approved to ensure no interruption of care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve 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. 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 spinal manipulation services to be provided by an out of network (OON) chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (code D5120) and a complete maxillary denture (code D5110).
You asked the Plan to pre-approve the complete mandibular and maxillary dentures. You say that your old dentures no longer fit because of the surgery you underwent on your face. You also say that the new dentures should be covered under your medical coverage due to the circumstances of this matter. The Plan denied your request. The Plan says these services are not covered by the health plan.
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. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (code D5120) and a complete maxillary denture (code D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zilretta injection.
You asked the Plan to pre-approve the requested injection. You say that you won't need a knee replacement if you get another shot. The Plan denied your request. The Plan says Zilretta injections can only be used once per knee per lifetime.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 requested injection. Our physician reviewer found that you have a history of osteoarthritis of the right knee. You previously received a Zilretta injection in the right knee in August 2019. Zilretta uses a proprietary formulation to provide pain relief over 12 weeks. Zilretta injections are not approved by the Food and Drug Administration (FDA) for repeat use and can only be used once per knee per lifetime. The documentation does not support that a repeat injection is medically reasonable and necessary. The documentation does not support that repeat injection is safe and effective. 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 requested injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Zilretta injection.