Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea second opinion with an out of network provider.You asked the Plan to pre-approvethe out of network care. You say that the requested out of network provider is the most qualified, with 38-years of experience in total join replacements. You say that treatment of knee stiffness status post total knee arthroplasty can be difficult secondary to extensor mechanism stiffness with potential risks of exposure during the revision, which justifies the need for treatment with the qualified physician being requested.The Plan denied your request. The Plan says there are equally qualified in network orthopedic surgeons who can supply a second opinion.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contractproviders for care. 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 out of network care. Our reviewer says that the criteria for coverage of out of network care have not been met. Our physician reviewer found the enrollee is status post left total knee replacement on February 13, 2020 with persistent pain and stiffness. There is reported imaging evidence of increased thickness of the medial patella and 9 degrees of internal rotation of the tibial component. She has significant loss of left knee functional range of motion. The referring orthopedic surgeon states that this surgeon had over 38 years of experience in the medical field specifically with knee/lower limbs and was the most qualified doctor for this enrollee to see for a second opinion. The Health Plan has offered two local in-network orthopedic surgeons and referral to a contracted tertiary level orthopedic surgeonif indicated. There is no compelling rationale to support the medical necessity of a second opinion with this specific orthopedic surgeon who is both out-of-network and out-of-area in another state. Therefore, the plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network orthopedic surgeon. There is nothing unique about her condition that would make it medically necessary for her to see the requested out-of-network provider. The plan has shown that they have in-network providers who meet the standards of care for treatment of her medical 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 the out of network care have not been met.Therefore, we decided that the Plan does not have to pre-approvea second opinion with an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve superficial radiation therapy.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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has basal cell cancer of the anterior right lower leg. The use of standard radiation therapy is consistent with the National Comprehensive Cancer Network (NCCN) guidelines; however, there is no discussion of the use of superficial radiation. Superficial radiation is not the standard of care and is not reasonable or medically necessary for 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve superficial radiation therapy.
Appeal type: Testing
Decision: Favorable

We decided that the Planhasto pre-approvea home sleep test for the enrollee.You asked the Planto pre-approvethe test. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere has not been a more than a 10% change in weight, and no surgery on the upper airway.The Plan must follow Medicare rules. Medicare rules say that sleep studies are covered if 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 test. Our reviewer says that the requested test is considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee isnoted in her history to have the following signs and symptoms of obstructive sleep apnea -snoring, occasional snort arousals, awakening with a dry mouth and daytime sleepiness. She also had a BMI of 32.4.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 test have been met.Therefore, we decided that the Planhas to pre-approvea home sleep test for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to an IRF.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 enrollee does not meet criteria for admission to an IRF. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's records received do not show that she requires this type of 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. The enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally medically stable andthe documentation does not support that she has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehab physician three times per week. While the enrollee may benefit from continuing physical therapy and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction of lesions (17000) provided on December 10, 2019.You asked the Plan to pay for the destruction of lesions. 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 17000 is  destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion.We asked our coder to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pay for the destruction of lesions. Our reviewer says that CPT code 17000 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do notinclude documentation to corroborate that a destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion was performed on December 10, 2019, therefore this service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the destruction of lesions have not been met.Therefore, we decided that the Plan does not have to pay for the destruction of lesions (17000) provided on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lower extremity.
You asked the Plan to pre-approve an MRI of the lower extremity. You say that the requested MRI of the lower extremity is medically necessary. The Plan denied your request. The Plan says the requested MRI of the lower extremity 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 an MRI of the lower extremity. Our reviewer says that the requested MRI of the lower extremity is not medically necessary. Our physician reviewer found the enrollee is with left knee pain after falling 6-7 weeks ago. There is no documentation of conservative measures for knee pain to include adequate physical therapy trial. There are no red flags for the requested MRI 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 an MRI of the lower extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the lower extremity.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the medical records provided 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 enrollee does require physical therapy and occupational therapy services
but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation
therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled
nursing facility level appears to be more appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 19, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an office setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from November 23, 2018 to November 27, 2018.You asked the Plan to waive the copayment for the inpatient hospital services. You say that you would like additional payment.The Plan denied your request. The Plan says that cost-sharing is a contractual obligation of the plan and cannot be waived.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 $395 copayment for each day for days 1 to 4 for Medicare-covered hospital care.You have been asked to pay a $1,580 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 4 for Medicare-covered hospital care 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 inpatient hospital services provided from November 23, 2018 to November 27, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits (99214) to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visits to be provided by an OON provider. You say that you would like to continue seeing this provider since you have attempted to make appointments with in-network physicians but have not been successful.The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.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-approveoffice visits (99214) 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-approvea neuropsychology consultation with an out-of-network provider.You asked the Plan to pre-approveneuropsychology service. You say that you believe that seeing this doctor will provide a more accurate assessment of your status than the in-network provider could, due to this provider's unique bilingual and bicultural heritage and cross-cultural experiences.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider with a translation service if needed.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 neuropsychology service. Our reviewer says that you do not meet the Medicare criteria for treatment with an out-of-network provider. Our physician reviewer found the documentation show that you are bilingual with Vietnamese being your first language. You experienced a traumatic brain injury in November 2019. You do not require neuropsychological testing performed by this out-of-network provider as the Plan is willing to provide translation services which are culturally competent. You can safely be seen by an in-network provider who is credentialed and maintained by the Plan and is culturally competent.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychology service have not been met.Therefore, we decided that the Plan does not have to pre-approvea neuropsychology consultation withanout-of-network provider.
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-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says the enrollee's needs could bemet 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 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 patient does require treatment by multiple therapies, including both physical therapy and occupational therapy, but does not require an intensive rehabilitation therapy program. Services could be provided at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade (J1745) 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 medical studies have not proven that this drug is helpful for treatment of the health problem.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Sjogren's Syndrome, Cogan's syndrome, and mixed bilateral hearing loss. Review of the documentation does not support the use of the medication for these diagnosis. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Remicade (J1745) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea L4-5/L5-S1 laminectomy for the enrollee.You asked the Planto pre-approvethe laminectomy. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested service is supported if you have never smoked.The Plan must follow Medicare rules. Medicare rules say thatitems 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 laminectomy. Our reviewer says that the requested laminectomy is not considered medically reasonable and necessary in this case. Our physician reviewer found the records show a history of the enrollee smoking. There is no clear documentation of a test showing smoking cessation.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 laminectomy have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea L4-5/L5-S1 laminectomy for the enrollee.