Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cardiac Blood Pool Imaging (78496).You asked the Plan to pre-approvethe Cardiac Blood Pool Imaging. You say that the cardiac imaging is medically necessary.The Plan denied your request. The Plan says the test is duplicative to previous tests performed.The Plan follows Medicare rules. Medicare rules say that Nuclear Imaging is not covered when the tests would provide no new information over tests already performed.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 Cardiac Blood Pool Imaging. Our reviewer says that rules for coverage have not been met. Our physician reviewer found the patient had two recent measurements of ventricular function, one by echocardiography and one by nuclear stress testing. Additional nuclear imaging would not change the course of treatment or provide any information the two previous tests have not already provided.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 Cardiac Blood Pool Imaging. have not been met.Therefore, we decided that the Plan does not have to pre-approveCardiac Blood Pool Imaging (78496).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluoxetine cap 40mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Fluoxetine cap 40mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December
26, 2018 through December 31, 2018.
You asked the Plan to waive the copayment for the inpatient stay. You say that you cannot afford the bill. You
say that you are not responsible for the bill. The Plan denied your request. The Plan says the copayment applied
correctly.
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 per day, for days 1-6 per stay.
You have been asked to pay a $825 copayment, which is less than the standard copayment for a 5-day inpatient
stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the inpatient stay provided from December 26, 2018 through December 31, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA) procedure.
You asked the Plan to pre-approve these services. You say that it's hard for you to walk due to pain. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a TKA is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have left knee pain that interferes with sleep and ability to walk. You failed adequate improvement with activity modification, topical ointments, and corticosteroid injections. The submitted x-ray report does not show evidence of advanced joint disease to support proceeding with joint replacement at this time. The requested left TKA is 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 total knee arthroplasty (TKA) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on
March 18, 2019.
You asked the Plan to reimburse you for the dental service. You say that the enrollee was diagnosed with
periodontal disease. You say that they receive periodontal maintenance in place of a prophylaxis cleaning. The
Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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, periodontal maintenance is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the
periodontal maintenance (D4910) provided on March 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous passive motion device, pad for water circulating heat unit, knee orthosis, walker and commode provided on August 2, 2019.
You asked the Plan to waive the coinsurance for these items. You say that this equipment was part of your hospital stay. The Plan denied your request. The Plan says that the claim processed correctly.
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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a 20% coinsurance for these items. These items fall within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the continuous passive motion device, pad for water circulating heat unit, knee orthosis, walker and commode provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (CPT 97140 and CPT 98940).
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.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The denied services - CPT 97140 and CPT 98940 - are not manual manipulation of the spine to correct subluxation. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (CPT 97140 and CPT 98940).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs to work on transfer, gait, and activities of daily living to make sure she can safely return home.The Plan denied your request. The Plan says the enrollee does not have complex medical conditions which require physician supervision, intensive rehab needs, or an intensive team for care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee isgenerally medically stable post humeral fracture and surgery. The shoulder is in a sling with non-weight bearing status. There is no evidence of acute or complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. While the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission.
You asked the Plan to pre-approve inpatient hospital care. You say that you perform these surgeries on an inpatient basis. The Plan denied your request. The Plan says the denial of authorization for inpatient place of service is correct, because there is no documentation of any reason an inpatient place of service would be needed.
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 unusual cases, 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 was correct in denying the request to pre-approve inpatient hospital care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient hospital admission. Our physician reviewer found in this case, comorbidities of hypertension and glaucoma are noted. There is no evidence that the enrollee's hypertension is uncontrolled or that she has other cardiopulmonary issues that would preclude treatment at an observation level of care. Therefore, the record does not show that the admitting physician reasonably expects that the enrollee's necessary hospital care will span at least 2 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.
You asked the Plan to pre-approve the aide. You say that this is medically necessary. The Plan denied your request. The Plan says home health aides are only covered under the Medicare Home Health benefit when delivered by a Medicare certified Home Health Agency as part of a physician ordered plan of care and incident to medically necessary skilled nursing services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the aide. Our reviewer says that the requested aide is not medically reasonable or necessary. Our physician reviewer found the requested home health aide services do not meet the definition of home health aide services as per Section 50.2 as the documentation does not reveal that the enrollee requires home health skilled nursing or skilled therapy services therefore the requested home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. 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 aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery services provided on November 19, 2019.
You asked the Plan to pay for the outpatient surgery services. The Plan denied your request. The Plan says services provided by non-participating providers are excluded for coverage.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient surgery services provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 7, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 pay for drug testing services provided to the enrollee on November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3-day inpatient stay for a spinal surgery for the enrollee.
You asked the Plan to pre-approve the stay. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not on the CMS inpatient-only list, and can be done as observation.
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 stay. Our reviewer says that the requested stay not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure may be safely performed with an observation stay. Inpatient care is not needed. 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 stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a 3-day inpatient stay for a spinal surgery for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvecontinued services. The Plan denied your request. The Plan says the enrollee is not demonstrating sustained improvement of function and mobility.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.Continued SNF services beyond March 22, 2020 was requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, youare at a maximal assist level with bed mobility and transfers. You can propel your wheelchair with minimal assist. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily 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 continued services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
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 these items are necessary for your condition. The Plan denied your request. The Plan says incontinence pads and diapers are not covered as they are non-reusable hygiene supplies.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance tablets.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee needs this medication as opposed to others available on the market.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveJardiance tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 1, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on November 1, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit and nail debridement provided on July 11, 2019.
You asked the Plan to pay for the physician services. You say that the services provided to the enrollee were not related to their hospice condition. You also say that the claim should be paid separately. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the domiciliary visit and nail debridement provided on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two retainer crowns and three pontics.You asked the Plan to pre-approvethe retainer crowns and pontics. The Plan denied your request. The Plan says the services are not medically necessary.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 the retainer crowns and pontics when the services are medically necessary and reasonable.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 retainer crowns and pontics. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for coverage for a fixed bridge has not been met since the documentation provided does not indicate that a crown is needed to restore an abutment retainer or that the missing teeth cannot bereplaced by a removable appliance.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontics have not been met.Therefore, we decided that the Plan does not have to pre-approvetwo retainer crowns and three pontics