Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The
Plan denied your request. The Plan says the enrollee's condition is not stable clinically at this time for transfer
to a LTACH.

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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Donnatal.

You asked the Plan to pre-approve Donnatal. You say that you have a severely disabling condition. The Plan denied your request. The Plan says this medication does not fall under Part B.

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 Donnatal.

Benefits for Donnatal 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist (G0151 x3) and direct skilled nursing services of a RN (G0299 x5).

You asked the Plan to pre-approve the services performed by a qualified physical therapist and direct skilled nursing services of a RN. You say that all of these interventions will help aid in keeping the enrollee from another hospitalization. The Plan denied your request. The Plan says the enrollee was educated on the new medication, and their clinical condition is stable. The Plan also says that there does not appear to be any medical complications that require the skills of a RN in the home.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 services performed by a qualified physical therapist and direct skilled nursing services of a RN. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary.

Our reviewer found that the enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or repeat hospitalizations. Our physician reviewer also found that the enrollee is independent with a home exercise program. 

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 services performed by a qualified physical therapist and direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve services performed by a qualified physical therapist (G0151 x3) and direct skilled nursing services of a RN (G0299 x5).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's respiratory status is unstable. The Plan denied your request. The Plan says the enrollee is not clinically stable for transfer.

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 was admitted to the acute care hospital with acute hypoxemic respiratory failure. She was found to have severe right ventricular dilatation and dysfunction. She is receiving appropriate care at the present acute care hospital. She does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not 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 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.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on December 6, 2020.

You asked the Plan to pay for the practitioner service. You say that the enrollee revoked the hospice benefit on December 5, 2020. You also say that the enrollee was not enrolled in hospice for the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on December 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on December 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four PT visits (G0151 x4).

You asked the Plan to pre-approve the PT visits. You say that you need these services. The Plan denied your request. The Plan says the documentation does not show or explain why the unique skills of a physical therapist are required to provide treatment.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 PT visits. Our reviewer says that the requested home health PT is not medically necessary. Our physician reviewer found the documentation does not support that you require additional skilled rehab services to provide treatment that is medically necessary. You do not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. Our physician reviewer also found that your function has improved with home health services and there is no indication that you require further 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 the PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four PT visits (G0151 x4).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve ten applications of Amnioband Allograft for the enrollee.

You asked the Plan to pre-approve the applications. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services are covered 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 applications. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has peripheral arterial disease as well. The ulcer is 2.1 cm by 2.5 cm with a clean granulation base without fibrotic tissue. The ulcer is full-thickness, not involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base. The left ankle brachial index is normal and the enrollee does not have diabetes. He has failed traditional wound therapy measures including five months of Unna boot. 

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 applications have been met. Therefore, we decided that the Plan has to pre-approve ten applications of Amnioband Allograft for the enrollee.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve artificial disc replacement and fusion (hybrid surgery) for the enrollee

You asked the Plan to pre-approve the surgery. You say that this should be paid for. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found hybrid cervical surgery remains experimental. More research is needed to show safety and efficacy of the artificial disc prosthesis when it is combined with fusion. Also, the prosthesis is not FDA approved for hybrid use.

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve artificial disc replacement and fusion (hybrid surgery) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on July 15, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was submitted with a laboratory place of service code but the record indicates the specimen was collected in an office setting.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, this claim was billed with a laboratory place of service code but the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on July 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider

You asked the Plan to pre-approve OON services. You say that physical therapy is medically necessary treatment for the enrollee. The Plan denied your request. The Plan says benefits are available with a provider in the 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 OON services. Therefore, we decided that the Plan does not have to pre-approve physical therapy 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-approve sacroiliac joint radiofrequency ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says research has not proven that this treatment is helpful.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is considered experimental/investigational because of the wide variation in pain relief reported in the
literature. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cyclobenzaprine, 10 mg tablet.

You asked the Plan to pre-approve cyclobenzaprine. You say that the requested drug should be covered. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 cyclobenzaprine, 10 mg tablet.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (S9122) provided on December 6, 2019, through December 20, 2019.

You asked the Plan to pay for the home health aide services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 S9122 is home health aide or certified nurse assistant, providing care in the home; per hour.

We find that CPT code S9122 is not supported in the record. Specifically, the record submitted does not include any documentation of home health aide services. The provider has not corroborated the documentation in the member's medical record to confirm that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services (S9122) provided on December 6, 2019, through December 20, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Testopel, 8 pellets every 3 months.

You asked the Plan to pre-approve the requested dosing. The Plan denied your request. The Plan says that the
drug is only covered for 6 pellets every 3 months.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested dosing. Our physician
reviewer found that the enrollee has hypogonadism, Peyronie's disease and benign pro-static hypertrophy. He
received six 75 milligram testosterone pellets on January 13, 2021. His total testosterone level was 384.5 on
February 16, 2021 Most patients will require more than six pellets per injection to achieve adequate therapeutic
levels and symptomatic relief. The average dose is 10 pellets per injection. In this case, adequate therapeutic
peak level was not achieved, and more pellets are 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 the requested dosing have been met. Therefore, we decided that the Plan has to
pre-approve Testopel, 8 pellets every 3 months.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar sacral orthosis (L0648) provided on October 26, 2020.

You asked the Plan to pay for a lumbar sacral orthosis. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document supplied as proof of delivery does not indicate the item provided. Therefore, we decided that the Plan does not have to pay for a lumbar sacral orthosis (L0648) provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 10, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on November 14, 2018 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are 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 medically necessary. The enrollee does not require
daily physician supervised care or a length of stay anticipated to be more than 25 days. The LTACH services
are 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.