Persius/hicric huggingface dataset:
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 this is the safest discharge plan and it allows for the highest potential level of recovery, prevents further deterioration and best use of medical management. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 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 they are 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical
necessity for you. The Plan denied your request. The Plan says rules for LTACH care have not been met
because the requested 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 considered medically reasonable and necessary in this case. Our
physician reviewer found that the documentation does not support that you require services at the LTACH that
are not available at the acute care hospital where you are currently receiving care. The documentation does not
support that an additional 25 days of hospitalization are reasonably expected for you 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services and a computed tomography (CT) scan (71250, 94060) provided March 10, 2021.

You asked the Plan to waive the copayment for the outpatient hospital services and CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 $275 copayment for outpatient hospital services and a $125 copayment for diagnostic radiology.

You have been asked to pay the allowable amount of $273.51 copayment for outpatient hospital services and a $125 copayment for diagnostic radiology. 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 outpatient hospital services and a computed tomography (CT) scan (71250, 94060) provided March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy to see if he can go back to an ambulatory state. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee would make practical improvement in a short amount of time.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 has had a significant decline in function. He is at a moderate assist level for bed mobility, maximal assist for transfers, dependent for ambulation, and maximal assist for activities of daily living. He does not require the intensity of services provided at an IRF. Specifically, he is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation.

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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a single photon emission computed tomography (SPECT) scan (78803).
You asked the Plan to pre-approve a SPECT scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this would exceed the enrollee's needs.
The Plan must follow Medicare rules. Medicare rules say that SPECT scans are medically necessary for the diagnosis of several clinical conditions as described in the NCD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a SPECT scan. Our reviewer says that the requested SPECT scan is considered medically reasonable and necessary in this case. Our physician reviewer found although there was no prior evidence of cardiac involvement from the systemic amyloid, surveillance of serum kappa light chains has shown a significant increase in one year. Given the availability of effective treatment for cardiac amyloid and published studies showing that early treatment is most effective, re-assessment for occult cardiac amyloid with SPECT technecium scanning is medically reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a SPECT scan have been met. Therefore, we decided that the Plan has to pre-approve a single photon emission computed tomography (SPECT) scan (78803).
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for outpatient mental health services (90837) provided on January 27, 2021.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says that the services were out-of-network and there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. The requested provider in this case is not a network provider with the Plan. The enrollee's benefits include services provided out-of-network. Therefore, we decided that the Plan has to pay for outpatient mental health services (90837) provided on January 27, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a set of partial dentures with a flexible base (D5225, D5226).
You asked the Plan to pre-approve partial dentures with a flexible base. You say that the requested items are a necessity for your care. The Plan denied your request. The Plan says the requested items are not a covered benefit.
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 set of partial dentures with a flexible base (D5225, D5226).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the High Intensity Focused Ultrasound (HIFU) of the prostate (55880).
You asked the Plan to pre-approve the HIFU. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that HIFU is medically necessary when certain criteria are met. 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 HIFU. Our reviewer says that the service is not medically necessary. Our physician reviewer found the member did not have prior radiation. 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 HIFU have not been met. Specifically, the enrollee has not received prior radiation. This means the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the High Intensity Focused Ultrasound (HIFU) of the prostate (55880).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 Eliquis 5 mg tablet.
You asked the Plan to pre-approve Eliquis. You say that this request is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your medical 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 Eliquis 5 mg tablet.
Benefits for Eliquis 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245), retainer crowns - porcelain/ceramic (D6740) for a bridge.
You asked the Plan to pre-approve a pontic and retainer crowns for a bridge. You say that you cannot eat with your existing partial denture. The Plan denied your request. The Plan says this service is not covered due to a denture previously covered within the past five years.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a bridge to replace a prosthetic appliance only after five years. We looked at the file, and Medicare rules. The Plan provided documentation showing that you previously had a partial denture covered on August 27, 2020. Based on this information, we determined that you are not yet eligible for coverage of a new prosthetic appliance. Therefore, we decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245), retainer crowns - porcelain/ceramic (D6740) for a bridge.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate artery embolization procedure.

You asked the Plan to pre-approve a prostate artery embolization procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.

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 a prostate artery embolization procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an 81-year-old male with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms. Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association guidelines do not recommend this procedure outside of a clinical trial setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prostate artery embolization procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate artery embolization procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the resin-based composite - two surfaces, anterior (D2331), the resin-based composite - one surface, posterior (D2391) and the resin-based composite - three surfaces, posterior (D2393) received March 8, 2021 from the out-of-network provider.
You asked the Plan to pay an additional amount for the resin-based composites. You say that the Plan should pay more money for the requested services. The Plan denied your request. The Plan says if you choose to see an out-of-network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment.
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 payment is in excess of what is covered under this benefit. For services obtained out-of-network the plan only pays up to a certain amount. If you choose to see an Out-of-Network dentist, you might be billed for any amount greater than
what the plan pays. The Plan agreed to pay 100% of the cost for the requested services up to the Plan's allowed amount. You are responsible for the difference between the Plan's allowed amount and what was billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the resin-based composite - two surfaces, anterior (D2331), the resin-based composite - one surface, posterior (D2391) and the resin-based composite - three surfaces, posterior (D2393) received March 8, 2021 from the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Escitalopram.

You asked the Plan to pre-approve Escitalopram. You say that other alternatives are not an option. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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 Escitalopram.

Benefits for Escitalopram 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for outpatient mental health services provided
by a Licensed Professional Counselor.
You asked the Plan to pre-approve the referral. You say that you want to continue The Plan denied your
request. The Plan says Medicare does not recognize Licensed Professional Counselors (LPC), as qualified
Medicare providers.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
The requested provider is not certified to bill Medicare. Based on this information, we decided that Medicare
rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to preapprove
a referral for outpatient mental health services provided by a Licensed Professional Counselor.
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the records show that the enrollee's care needs are routine, and a team of providers is not required. The necessary services can be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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.