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

We decided that the Plan does not have to pre-approve cataract surgery on your implants.

You asked the Plan to pre-approve cataract surgery on your implants. You say that you need a correction. The Plan denied your request. The Plan says cataract surgery is not medically reasonable or safe at this time, you should first see an optometrist about glasses.

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 cataract surgery on your implants. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has a decentered lens. The ophthalmologist has recommended optometry evaluation. This was performed and glasses prescribed. The elements of the coverage criteria 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 cataract surgery on your implants have not been met. Therefore, we decided that the Plan does not have to pre-approve cataract surgery on your implants.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 10, 2020.

You asked the Plan to pay for the lab services. You say that you provide timely testing. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The submitted claim shows a place of service as an independent lab. The records provided do not show that the enrollee's specimen was obtained at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing care (G0299).

You asked the Plan to pre-approve home health skilled nursing care. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is no longer medically necessary.

The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. 

There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing care (G0299).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D Biopsy provided on October 16, 2020.

You asked the Plan to pay for the WATS 3D Biopsy. The Plan denied your request. The Plan says this is 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 WATS 3D Biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee underwent an esophagogastroduodenoscopy (EGD) for anemia. The pathology report indicated the absence of intestinal metaplasia and did not recommend further testing. The records provided do not support the medical necessity and reasonableness of the requested procedure as defined by Medicare rules. 

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 WATS 3D Biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D Biopsy provided on October 16, 2020.
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 enrollee would benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines for coverage of IRF care. The Plan says that the enrollee can safely receive the care needed in a less intensive setting of 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic facet joint block.

You asked the Plan to pre-approve a therapeutic facet joint block. You say that you are in unbearable pain. The Plan denied your request. The Plan says there is no documentation as to why the enrollee cannot have radiofrequency ablation for her lumbar spine.

The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary when there is documentation regarding why the enrollee is not a candidate for radiofrequency ablation.

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 therapeutic facet joint block. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has low back pain (LBP) due to moderate to severe lumbar facet arthropathy. The LBP is located along the right lumbar paraspinal region and is described as an achy sensation which is made worse with standing and movement. There is no gross motor weakness, saddle anesthesia, or incontinence symptoms. The enrollee has received physical therapy. An MRI revealed lumbar spondylosis with mild to moderate stenosis; mild degenerative changes most prominently at L4-L5 and L5-S1 with mild narrowing of the neural foramen. The enrollee is status post (s/p) lumbar facet joint block in 2020 as part of a diagnostic plan to determine appropriate management. She had good relief of pain from this procedure which was long-lasting. The enrollee had radiofrequency ablation (RFA) on March 26, 2021. The next step is typically a repeat RFA if the first one was successful. There is no documentation as to why radiofrequency ablation is not medically appropriate. 

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 therapeutic facet joint block have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic facet joint block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic nerve block injection (64624).

You asked the Plan to pre-approve a diagnostic nerve block injection. You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a diagnostic nerve block injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of genicular nerve blocks and radiofrequency ablation after total knee arthroplasty is the subject of ongoing clinical trials and is experimental/investigational.

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 diagnostic nerve block injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic nerve block injection (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.

You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says the chronic pain does not meet the guidelines.

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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve blocks are 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 the blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional PT visits.

You asked the Plan to pre-approve six (6) additional PT visits. You say that the additional PT is medically necessary. The Plan denied your request. The Plan says the additional PT is not medically necessary.

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 six (6) additional PT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and was approved additional therapy to ensure competence in a home exercise program. The records do not demonstrate that the ongoing 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 by or under the supervision of a therapist. The enrollee has been approved for ample time to be instructed in and competent in an effective home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional PT visits.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for pharmacogenomic testing provided on January 14, 2021.

You asked the Plan to pay for pharmacogenomic testing. You say that Medicare has covered this testing as medically reasonable and necessary since 2014. The Plan denied your request. The Plan says that this testing was not medically reasonable and appropriate for the enrollee's clinical situation.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for pharmacogenomic testing provided on January 14, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs admission to a long-term SNF for treatment of her dementia. The Plan denied your request. The Plan says clinical information for the enrollee shows no evidence of a skilled need that is required on a daily inpatient basis.

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 the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (J0129).

You asked the Plan to pre-approve the Orencia. You say that the prescription of Orencia once a week is medically appropriate and necessary and should be covered. You also say that the Orencia appears to have put the enrollee into remission for over 1 year. The Plan denied your request. The Plan says this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Orencia (J0129).

Benefits for the Orencia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide.

You asked the Plan to pay for a stair glide. You say that you were told you would be reimbursed. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide.
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 requested admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for initial observation care (99220) provided January 5, 2021.

You asked the Plan to waive the copayment for initial observation care. You say that you would like this copayment waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 $400 copayment for outpatient hospital observation. 

You have been asked to pay total cost share of $198.91 for initial observation care which is less than or equal to the required $400 copayment. This service falls within the outpatient hospital observation 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 initial observation care (99220) provided January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay for shoulder arthroplasty.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation that the enrollee would require a greater than 2 midnight stay.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the shoulder surgery may be safely performed with an observational stay of 48 hours. An inpatient admission 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay for shoulder arthroplasty.