Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does nothave to pre-approve physical therapy services to be provided by out of network provider.You asked the Plan to pre-approve physical therapy services. You say that you are requesting a reconsideration of the denial for out-of-network physical therapy services for lower back pain. You saw a network provider without relief of your symptoms and would prefer to go to this out-of-network provider as you have worked with this provider in the past.The Plan denied your request. The Plan says services must be provided by a network provider. An out-of-network provider is covered for urgent or emergent care out of the local coverage area. If there is not a network provider available who can meet your health needs or if you will be temporarily outside the local coverage area and need dialysis. The Plan has multiple in-network physical therapy providers and contacted the provider, who have openings within a week. The Plan has determined that there are multiple in network providers available that have the credentials to meet your needs.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services to be provided by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forMagnetic Resonance Imaging (MRI) of the Head (70551).You asked the Plan to pay forthe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 pay for the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found a trial of Sinemet was planned in the initial visit but no recent progress notes were provided showing evidence of failure of this medication or other findings suggestive of another neurological condition which might warrant brain 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 the MRI have not been met.Therefore, we decided that the Plan does not have to pay forMagnetic Resonance Imaging (MRI) of the Head (70551).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on September 24, 2019 by the
out-of-network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for
services rendered to the Plan's member on date of service September 24, 2019. You say that the notes provided
will support the need for service. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. There is no referring provider listed. The plan did not authorize any services for the Facility or the Provider, who are non-participating providers. The services are not considered urgent/emergent in nature. There is no referring provider listed. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on September 24,
2019 by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on August 28, 2019 by an out of network provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested providerin this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided on August 28, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 16, 2019 by an out of network provider. You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record does not show that the member required emergent care, kidney dialysis or services that providers in the Plan cannot provide or that the member is new to the Plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 16, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 12, 2019 by out of
network provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says
that the rendering facility, is a non-participating 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 12, 2019 by
out of network provider.
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-approvethe LTACH 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 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure, in the setting of ALS. The enrollee has been maintained on high-flow oxygen and BiPAP. The enrollee is not intubated/ventilated, though an elective tracheotomy for long-term care is being considered. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 22, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that a primary care physician did not order these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for physician services provided on July 22, 2019 by out of network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Reblozyl.
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says that Reblozyl is 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 Reblozyl. Our reviewer says that Reblozyl is medically reasonable and necessary. Our physician reviewer found that Reblozyl is supported by major drug compendia for off-label use for anemia due to lower-risk myelodysplastic syndromes with ring sideroblasts. The enrollee meets these criteria. This drug is reasonable and 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 Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve Reblozyl.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from July 25, 2019 through August 1, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plansays that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusualcases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the recordshowed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from July 25, 2019 through August 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 9, 2019
You asked the Plan to pay for hospital clinic services. You say that you are appealing based on medical
necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 9, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis, and the ankle foot orthosis provided on July 23, 2019.
You asked the Plan to pay for the wrist hand orthosis (L3916), and the ankle foot orthosis (L1971). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis, and the ankle foot orthosis provided on July 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MAZE cardiac ablation procedure.
You asked the Plan to pre-approve the MAZE procedure. You say that this is a medically necessary surgery for
this enrollee's condition. The Plan denied your request. The Plan says current literature does not support the
medical necessity of this surgery in this situation.
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 MAZE procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the records the patient has paroxysmal atrial fibrillation that is now
asymptomatic and mostly suppressed with propafenone medication. In this circumstance the medical necessity
for additional ablation procedure is questionable at best. Moreover, if an additional ablation procedure is
thought to be necessary then a third transcatheter procedure has not been shown to be inferior compared to a
standalone surgical MAZE. Surgical MAZE procedures are generally considered appropriate only when open
heart surgery is already planned for another purpose such as CABG and/or valve repair/replacement. Current
guidelines do not support the medical necessity for a standalone MAZE procedure.
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 MAZE procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve MAZE cardiac ablation procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a heart rhythm analysis, interpretation and report of 48-hour electrocardiographic (EKG) (93226) provided on July 8, 2019 by the out of network provider.
You asked the Plan to pay for a heart rhythm analysis, interpretation and report. You say that you are seeking reconsideration because you say the kit provided did not mention the requirement for an in-network provider. The Plan denied your request. The Plan says while you are enrolled in the plan you must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. The claim does not meet urgent or emergent criteria.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a heart rhythm analysis, interpretation and report of 48-hour electrocardiographic (EKG) (93226) provided on July 8, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the needs are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic shoulder arthroscopy with rotator cuff
repair and biceps tenodesis
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 left shoulder bursitis.
There is no documentation of imaging studies that correlate with a physical exam showing the diagnosis to
treat. The requested surgery is therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a diagnostic shoulder arthroscopy with rotator cuff repair and biceps tenodesis
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 you were independent and active before your hospitalization. The Plan denied your request. The Plan says intensive rehab program will not significantly impact your condition differently compared to a less intensive level. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that post-operatively, you are hemodynamically stable and pain appears controlled. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are at minimal assist for functional transfers and activities of daily living. You do not require  treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.