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

We decided that the Plan does not have to pre-approve CT Scan of the heart with calcium scoring (75571).You asked the Plan to pre-approve the CT Scan. You say that the CT Scan with calcium scoring is medically necessary. The Plan denied your request. The Plan says the submitted medical records do not document any medically indicated need for this test.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 CT Scan. Our reviewer says that there is a clear statin therapy indication and the decision has already been made to treat the member's condition with atorvastatin. CT calcium scoring will not affect the decision to start this therapy Our physician reviewer found as the CT calciumscoring is not being used to consider a change in the clinical management, it would not be considered medically necessary or indicated based on guideline recommendations.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 CT Scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT Scan of the heart with calcium scoring (75571).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent hospital care services provided on August 24, 2019 and August 25, 2019.You asked the Plan to pay forthe subsequent hospital care services. You say that the enrollee was not in hospice at the time of service.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on August 18, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care services provided on August 24, 2019 and August 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.You asked the Planto pre-approvethese services. You say that the enrollee cannot return to the assisted living facility.The Plan denied your request. The Plan says the admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 28,  2020 with hematuria. He had stable vital signs and received routine Foley catheter care. He received physical and occupational therapy in the hospital and needs varied assist with activities of daily living. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 5, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial of payment.The Plandenied your request. The Plan says the services are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on August 5, 2019.
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 services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include respiratory care with oxygen supplementation, surveillance laboratory studies, wound care, soft mechanical diet, pain medication, patches to knee, and therapy services. The The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on September 18, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that you should not have been charged for the second mammogram because it is not necessary because the scar tissue shows up on the scan every year. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $50 copayment for other outpatient diagnostic testing. You have been asked to pay a $50 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received a screening mammogram on September 16, 2019 which exhausted the breast cancer screening benefit.
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 mammogram provided on September 18, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of upper extremity.
You asked the Plan to pre-approve MRI. You say that your wrist is practically immovable and extremely painful, and you need to know what is wrong. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the requested MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MRI. Our reviewer says that you meet the Medicare criteria for the requested MRI. Our physician reviewer found you were treated with antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, splinting, and ice. You noted improvement, however, 1 week later you again had pain and swelling. MRI is an appropriate test for inflammation, foci of infection, and other lesions not readily identified. Therefore, the requested MRI is medically reasonable and necessary for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of upper extremity.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea spinal distraction device.You asked the Planto pre-approvea spinal distraction device. You say that this service is medically necessary.The Plandenied your request. The Plansaysthis service is 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 a spinal distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a spinal distractiondevice is experimental. More research is needed to show safety and efficacy.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 spinal distraction device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea spinal distraction device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee. You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they aremedically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheelchair provided on September 18, 2019.
You asked the Plan to waive the coinsurance for the wheelchair. You say that you did not use the wheelchair. You say that you were billed for a month for a wheelchair you did not have. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay a total of $17.86 for the wheelchair and supplies.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
September 18, 2019
Wheelchair
$31.99
20%
$6.40
September 18, 2019
Seat Cushion
$40.95
20%
$8.19
September 18, 2019
Heel Loop/Holder
$16.34
20%
$3.27
TOTAL:
$17.86
The wheelchair falls within the "Durable medical equipment (DME) 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 wheelchair provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forspecial supplies (CPT 99070) provided to the enrollee from August 21, 2019 to August 30, 2019.You asked the Planto pay forthe supplies. You say that this should be paid for.The Plandenied your request. The Plansayspayment for this code is always bundled into payment for other services not specified, and no separate payment is made.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99070 is "supplies and materials, except spectacles, provided by the physician or other health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]."We find that CPT code 99070 is not supported in the medical record. Specifically, this code cannot be billed separately, and separate payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.Therefore, we decided that the Plandoes not haveto pay forspecial supplies (CPT 99070) provided to the enrollee from August 21, 2019 to August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for Budesonide.You asked the Plan to pre-approvea tier exception for Budesonide. You say that the cost of this medication is too expensive.The Plan denied your request. The Plan says this drug is not eligible for a tier exception because it is covered under Medicare Part B.The Plan must follow Medicare rules. The rules also say that Medicare allows Part D sponsors to exempt a formulary tier, in which it places very high cost and unique items, from tiered cost-sharing exceptions.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Budesonide have not been met. Specifically, Medicare Part B Drugs are not eligible for tier exceptions. The requested drug is covered under Medicare Part B, in thiscase. Therefore, we decided that the Plan does not have to pre-approvea tier exception for Budesonide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care with acute mental status changes and acute encephalopathy. He is on daily peritoneal dialysis. He was taking Valacyclovir with shingles. His prior level of function was independent with mobility and activities of daily living. He lives with his spouse in a single story home with 2 steps to enter. His current level of function is minimal assist with bed mobility, minimal assist with sit to stand, ambulating 10 feet with a rolling walker with minimal assist, minimal assist with dressing, and minimal assist with basic activities of daily living. Based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or acute rehab nursing care. While he may benefit from continuing physical therapy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical stimulation device used for cancer treatment (E0766).You asked the Plan to pre-approve the electric stimulation device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan saysthe tumor is continuing to progress, and thus the TTFT does not meet coverage criteria.
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 tocarefully 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 electric stimulation device. Our reviewer says that TTF is not reasonable and necessary for the treatment of recurrent GBM. Our physician reviewer found the use of Oputne (Tumor treatment field therapy (TTF)) is not considered a standard of care and not supported per Medicare guidelines.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the electric stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical stimulation device used for cancer treatment (E0766).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve image-guided radiation therapy for the enrollee.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested treatment is not supported for the enrollee's cancer type.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 topre-approve the therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found no rationale is provided for why IGRT is needed for this enrollee. While radiation simulation, planning (2D/complex) and treatment with 10 fractions is standard and medically necessary, IGRT is not, particularly without any plausible justification.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 therapy have not been met.Therefore, we decided that the Plandoes not haveto pre-approveimage-guided radiation therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forportable oxygen contents provided from May 26, 2019 through October 26, 2019.You asked the Plan to waive the coinsurance forportable oxygen contents. You say that you were not informed you had to pay for your oxygen.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment.You have been asked to pay a total of $79.68 for the portable oxygen contents. Portable oxygen contents fall within the "Durable medical equipment (DME) 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 youenrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forportable oxygen contents provided from May 26, 2019 through October 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myofascial release therapy.You asked the Plan to pre-approve the myofascial release therapy. You say that you feel as if you have the legs of an older person and believe thistherapy will help you. The Plan denied your request. The Plan says neither Medicare nor the Plan cover myofascial release therapy.The Plan must follow Medicare rules. Medicare does not cover the services of a massage or myofascial release therapist.Therefore, we decided that the Plan does not have to pre-approve myofascial release therapy.