Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) provided on February 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the eye exam. You say that you are in the Plan's network. The Plan denied your request. The Plan says you are not in the Plan's network, and criteria for obtaining out-of-network coverage have 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 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 had network providers available who could have provided 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 eye exam (92014) provided on February 22, 2021 by an out of network (OON) provider.
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 the stay is medically necessary. 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 the enrollee was admitted with septic shock from pneumonia and was also found to have cytomegalovirus (CMV) colitis and cholecystitis during her hospital course. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the rehab is necessary to improve your condition. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily 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 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 you were admitted to the acute care hospital for a scheduled hip replacement. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 81-year-old male with gastrointestinal bleed, anemia and bowel obstruction. You are currently receiving care in an inpatient rehabilitation facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation.
You asked the Plan to pre-approve additional miles. You say that you need transportation to your procedure. The Plan denied your request. The Plan says your benefit only allows 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The file shows that routine transportation for over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers transportation for up to 50 one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code 99213) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office services. You say that the services are necessary. The Plan denied your request. The Plan says your records do not indicate that you have an emergent or urgent medical condition or are in need of specialized service. The Plan states there are in-network provider(s) within a reasonable distance from your location that can provide this service or item.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services (CPT code 99213) to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not indicated to evaluate the kidney.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee had two
imaging studies in 2020 that did not show renal stones. There is no indication for the CT scan that was
requested. If the enrollee is symptomatic, a renal ultrasound would be indicated.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the abdomen and pelvis.
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 medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation needs.
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 th
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 the stay is medically necessary. 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 the enrollee was admitted with pneumonia and subsequently developed respiratory failure. The enrollee developed encephalopathy and Clostridium dificile colitis. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) provided August 7, 2020.
You asked the Plan to pay for the acupuncture services. You say that upon verification of this enrollee's policy, you were informed that there is no visit maximum for acupuncture services along with 100% coverage of the UCR fee for these services. Process and reimburse accordingly. The Plan denied your request. The Plan says this is a non-covered provider as the service was rendered by a licensed acupuncturist and not a physician.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the service was rendered by a licensed acupuncturist. The services must be provided by a legally qualified physician, practicing within the scope of their license. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810) acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes (97811) provided August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 26, 2020.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36523 to support their denial. However, LCD L36139, L36129 and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129 and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 26, 2020.
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 meets admission criteria for LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide aquatic therapy.
You asked the Plan to provide therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises (97113). You say that warm water therapy was very helpful for the enrollee's movement and pain. The Plan denied your request. The Plan says the aquatic therapy is no longer so complex that it requires a therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises (97113). Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the available records the patient's therapy at this point does not appear to require a skilled therapist but is simple in-water walking and stretching. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. Further utilization of the pool on her own with a caregiver to continue the in-water walking and stretching program appears appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises (97113) have not been met. Therefore, we decided that the Plan does not have to provide aquatic therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary, as there is appropriate care available in-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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this is medically necessary. The Plan denied
your request. The Plan says this service is considered experimental.
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 Vertiflex surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found This 73-year-old female was being treated for spinal stenosis, lumbar region, with
neurogenic claudication. She presented with low back and leg pain on the right side. The pain is radiating from
the low back to the knee. Exam reveals the gait is slow and cautious. However, current evidence based medical
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the
'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome
studies to support the use of this device for this enrollee's medical condition as discussed above. There is no
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this
request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and L4-5 is 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat Zilretta injections.
You asked the Plan to pre-approve these 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had Zilretta injections to both knees on September 9, 2020 and March 10, 2021. The safety and efficacy of repeat Zilretta injections has not been demonstrated and is not supported by the Medicare-approved drug compendia. The 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat Zilretta injections.