Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve physical therapy services to be provided by a network provider. We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network provider.
You asked the Plan to pre-approve physical therapy services. You say that you would like the plan to reconsider their denial. The Plan says that the requested services are not medically necessary.
We decided that the Plan has to pre-approve physical therapy services to be provided by a network provider.
Our doctor says that the requested physical therapy services are medically reasonable and necessary. Our doctor found that the enrollee has neck pain radiating to the shoulders, tingling, numbness, weakness and dizziness for three months with a diagnosis of Cervical spondylosis. The enrollee was evaluated by physical therapy on December 19, 2019 and was found to have decreased range of motion, strength, and tenderness on palpation. The documentation supports that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The documentation clearly shows that the unique skills of a professional therapist are required to safely and effectively provide treatment for this enrollee's neck pain with documented deficits. Therefore, we decided that the Plan has to pre-approve physical therapy services to be provided by a network provider.
We also decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam for enrollee.You asked the Plan to pre-approve Lorazepam. You say that the preferred drug is not in the best interest of the enrollee.The Plan denied your request. The Plan says Lorazepam to be taken at home is not covered under the Part B 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 Lorazepam for enrollee.Benefits for Lorazepam may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 continuity of care being offered will give the enrollee the best opportunity to improve function and return to baseline. The Plan denied your request. The Plan says it is not medically necessary for the enrollee to be admitted to an IRF. The Plan says that the enrollee's needs can be met at a lower level of care.
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's medical conditions appear stable. There are no complex wound care needs. The enrollee does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, the enrollee is ambulating greater than household distances with minimal assistance and does not require an intensive rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility level. 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-approveendovenous radiofrequency ablation (ERFA) of the greater saphenous veins.You asked the Plan to pre-approve the ERFA treatment. You say that this is medically necessary.The Plan denied your request. The Plan says there is insufficient documentation to support that the symptoms have not responded to conservative management.The Plan follows Medicare rules. Medicare rules say that RFA of varicose veins may be considered reasonable and necessary when conservative therapy has failed to alleviate the issue.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 ERFA treatment. Our reviewer says that the requested services are not considered medically reasonable or necessary. Our physician reviewer found the patient complains of radiating leg pain and numbness of a severity to cause limping. The patient has a significant history of peripheral artery disease with intervention in the past. The documentation has conflicting information ranging from symptoms lasting several months and not wearing support hose to having failed six months of stockings. The documentation does not satisfactorily support that bilateral saphenous ablation will help the symptoms in his left leg. Criteria for coverage not met and documentation does not satisfactorily support the medical necessity of the procedures. 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 ERFA treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenousradiofrequency ablation (ERFA) of the greater saphenous veins.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Inspire Upper Airway Stimulation (UAS) device
(0466T and 64568).
You asked the Plan to pre-approve the Inspire Upper Airway Stimulation (UAS) device (0466T and 64568).
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
requested service is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The Inspire Upper Airway Stimulation (UAS) device (also known as
a hypoglossal nerve stimulator) with procedure code 0466T is currently excluded from Medicare coverage as
not proven effective or not medically reasonable or necessary. Therefore, we decided that the Plan does not
have to pre-approve the Inspire Upper Airway Stimulation (UAS) device (0466T and 64568).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement power mobility device.You asked the Plan to pre-approvea replacement power mobility device. You say that the power wheelchair provided is too small for your frame and does not fit properly.The Plan denied your request. The Plan says the assessment shows your current power wheelchair remains the most appropriate and safest mobility device for you.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The record does not show that you had a change in medical condition to warrant the power mobility deviceat issue.Therefore, we decided that the Plan does not have to pre-approvea replacement power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on April 11, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 20610 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 20612 is aspiration and/or injection of ganglion cyst(s) any location.We find that CPT code 20612 is not supported in the medical record. Specifically, the records do not contain documentation of aspiration or injection or ganglion cysts of any location. 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 haveto pay forthe services rendered on April 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TECENTRIQ for enrollee.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unresectable hepatocellular cancer for which TECENTRIQ in combination with Bevacizumab is requested. The requested use is not FDA-approved for supported by Medicare compendia. The TECENTRIQ with Bevacizumab is considered investigational in nature and therefore not safe and effective or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does no thave to pre-approve TECENTRIQ for enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve8 additional physical therapy (PT) visits.You asked the Plan to pre-approve8 additional physical therapy (PT) visits. You say that the remaining 8 additional PT visits are medically necessary.The Plan denied your request. The Plan says the remaining 8 additional PT visits 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 8 additional physical therapy (PT) visits. 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 enrollee is with a diagnosis of Parkinson's disease and unsteadiness on feet. The Plan received a request for 10 additional PT visits. The Plan approved 2 additional PT visits. At issue is the remaining 8 additional PT visits. The enrollee has been receiving PT since 11/5/19 2-3 times a week per Neurology. His Physician's note dated 1/14/20 states significant dementia. As per neurology note dated 2/12/20 he carries a diagnosis of Parkinson's disease, Progressive dementia and Insomnia. His gait is slow and walks with a walker. He lives in an Assisted Living setting. There is slow progression of his cognitive decline. Based on review of the medical records most importantly physical therapy notes, the enrollee is not making any progress in the setting of a neurodegenerative disease (Parkinson's disease) and progressive Dementia. He is not expected to make any gains in his function with additional PT visits. He does not meet the criteria to continue therapies. PT is not reasonable and necessary as there must be an expectation that the condition will improve significantly in a reasonable and generally predictable periodbased on the physician's assessment of the enrollee's rehabilitation potential. After 12 PT visits this enrollee has made minimal gains and has unchanged deficits. The unique and specialized skills of a physical therapist are not required to continue to treat this enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional physical therapy (PT) visits have not been met.Therefore, we decided that the Plan does not have to pre-approve8 additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on August 29, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee on August 29, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that it appears the enrollee is at his baseline in terms of physical functioning and his needs appeal to be custodial at this time.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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. 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 follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully usesthe appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea fixed bridge (pontic and retainer crowns) for teeth #'s 7-11.You asked the Planto pre-approvethe fixed bridge. You say that the enrollee suffered a stroke which led to a fall in which dental damage was sustained. Tooth #9 required extraction and other teeth remain broken. This bridge is needed to preserve the broken teeth and provide for adequate nutrition and self-image. You believe this is medically necessary.The Plandenied your request. The Plansaysreplacement of teeth is not covered by Medicare.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, and replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare regardless of the cause of the injury.Therefore, we decided that the Plandoes not haveto pre-approvea fixed bridge (pontic and retainer crowns) for teeth #'s 7-11.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (CPT 81240, 81241, 81400, 81401, 82955) provided to the enrollee on April 5, 2019.You asked the Plan to pay forthe service. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes remain not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code  is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of thepatient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records do not indicate where the laboratory specimen was obtained. Based on this information, we decided that Medicare rules for coverage of the service have not been met.Therefore, we decided that the Plan does not have to pay forlab services (CPT 81240, 81241, 81400, 81401, 82955) provided to the enrollee on April 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelower partial dentures.You asked the Plan to pre-approvethe requested dentures. You say that you are unable to eat due to the improper fitting of your dentures.The Plan denied your request. The Plan says the service requested has already been exhausted in the last 60 months.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. We looked at the file, and Medicare rules. The file shows that youreceived the requested dentures on July 22, 2019. Your plan only covers dentures once every 60 months. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does nothave to pre-approvelower partial dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed.
You asked the Plan to pre-approve the total electric hospital bed. You say that the enrollee is immobile and unable to move so the bed is needed. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature and therefore is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea nerve block injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthis type of nerve block is not intended to treat headaches.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found this approach is considered experimental/investigational since large scale randomized controlled trials have not beenperformed. Therefore, the request is considered not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea nerve block injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on July 15, 2019 and September 5, 2019.
You asked the Plan to waive the copayment for the office visits. You say that you do not understand the denials. The Plan denied your request. The Plan says the copayments applied correctly.
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 $45 copayment for services obtained from an out-of-network primary care provider. You have been asked to pay a $45 copayment for each office visit. The total amount you owe is $90 ($45/visit x 2 visits = $90). The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 office visits provided on July 15, 2019 and September 5, 2019.