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

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy visits. You say that this is medically necessary. The Plan denied your request. The Plan says you do not require the specialized skills of a physical 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 pre-approve additional physical therapy visits. 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 you have had had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. Although you are resistant to nursing staff performing range of motion exercises, the documentation does not support that a skilled therapist must perform these exercises.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the glucose monitor has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block (64454) to treat knee pain.

You asked the Plan to pre-approve genicular nerve block. You say that the plan had approved the nerve block for your back and the pain got better and got you walking again. You do not understand why they can't approve the nerve block on your left knee. The Plan denied your request. The Plan says genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain and the enrollee is not enrolled in a Medicare approved clinical trial for evidence development.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block (64454) to treat knee pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power operated vehicle.

You asked the Plan to pre-approve a group 1 power operated vehicle. You say that this device is necessary because you are on your feel all day. The Plan denied your request. The Plan says the request for the power operated vehicle does not meet Medicare requirements.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic substrate crown (D2740) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 porcelain/ceramic substrate crown (D2740) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.

You asked the Plan to pre-approve therapeutic continuous glucose monitor. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for the glucose monitor has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electron beam computed tomography (EBCT).

You asked the Plan to pre-approve the services. You say that this is medically necessary to determine if there is blockage. The Plan denied your request. The Plan says this is not a covered service and is not medically necessary.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you have evidence of atherosclerotic vascular disease with prior history of cerebrovascular disease, and aortic aneurysm but have no symptoms suggesting cardiac disease such as chest pain or abnormal EKG. Your lipid profile shows well-controlled hyperlipidemia. CMS guidelines do not provide coverage for screening tests in patients who have no cardiac symptoms. The records do not show a plan of what an elevated calcium score would mean to the treatment plan as the integrity of the coronary arteries is not assessed using non contrast CT imaging.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve electron beam computed tomography (EBCT).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve home health care. You say that you need physical therapy due to knee surgery and are bedridden. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the requested services are not covered by Medicare.

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 home health care services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TumorNext lynch testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says it cannot be said that this next generation sequencing is reasonable and necessary at this time.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with grade 2, stage pT1a, uterine cancer. The cancer was determined to be low risk. Adjuvant therapy was not recommended. Ongoing surveillance was planned. There is no evidence that the cancer has recurred, relapsed, metastasized or not responded to therapy. As such, the documentation does not support that the requested panel testing is medically necessary or 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 the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve TumorNext lynch testing for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the allograft injection provided on April 28, 2020.
You asked the Plan to issue reimbursement for the allograft injection. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the allograft injection performed during the spinal procedure was 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 pay for the allograft injection. Our reviewer says that the allograft injection provided was not medically reasonable and necessary in this case. Our physician reviewer found that stem cell injections remain experimental for use in the spine. More research is needed to show the safety and efficacy of stem cell use in the spine. 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 allograft injection have not been met. Therefore, we decided that the Plan does not have to issue reimbursement for the allograft injection provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 29, 2020 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without prior authorization.
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 laboratory services provided on October 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and vaccines provided by an out-of-network provider on September 16, 2020.
You asked the Plan to pay for the office visit and vaccines. You say that the enrollee needed to see a physician for a proper diagnosis and was not near their primary care physician. You say that the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with 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 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 office visit and vaccines provided by an out-of-network provider on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that this is needed due to your previous surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital for bacteremia and renal failure. The enrollee was transiently intubated but is no longer intubated or ventilated. The enrollee is receiving a prolonged course of antibiotics and has been started on hemodialysis. There is no evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current facility until such time no acute services are required. Medicare coverage criteria for transfer are not met. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0676).

You asked the Plan to pay for an intermittent limb compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of venous thrombosis.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PCD (E0651) and a segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a PCD and a segmental pneumatic appliance. You say that all necessary criteria, including the four-week trial, have been met. The Plan denied your request. The Plan says rules for approval have not been met because the requirement for a four-week trial for lymphedema has not been satisfied in full.

The Plan follows Medicare rules. Medicare rules say that pneumatic devices are covered when medically necessary for the treatment of lymphedema which is documented to be unresponsive to other clinical treatment over the course of a required four-week trial.

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 PCD and a segmental pneumatic appliance. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found that the documentation does not reveal objective evidence of a four-week trial with detailed pre- and post- measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the four-week trial. Medicare coverage criteria for E0651 have not been met.

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 PCD have not been met. Furthermore, the requested segmental pneumatic appliance is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve a PCD (E0651) and a segmental pneumatic appliance (E0667).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve the home health services.. You say that you would like reconsideration because you require home health services. The Plan denied your request. The Plan says there is no physician order for this service and you are not currently receiving this service.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services. have not been met. Specifically, the record indicates that your doctor has not certified your need for home health care services. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on November 16, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you were told this would be covered. The Plan denied your request. The Plan says that they have already covered a panoramic x-ray.
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 one panoramic x-ray every five years. We looked at the file and Medicare rules. The file indicates the Plan has covered a panoramic x-ray on October 12, 2020, which is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on November 16, 2020.