Persius/hicric huggingface dataset:
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 home health services. 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 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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. As such, associated home health aide services are not shown to be medically necessary, reasonable or coverable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on June 3, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because the level of service has been applied appropriately. The Plan denied your request. The Plan says the documentation does not support the level of service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 emergency department visit. Our reviewer says that CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate the service provided was an Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Therefore, this service should not be reimbursed at the level billed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires the utilization of in-network providers unless the Plan pre-approves out-of-network services in non-emergent situations. Authorization for out-of-network services was not obtained.
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 physician's services. 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 October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care following an elective right knee arthroplasty, for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 looked at 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. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT Code 27447 is not listed on the CMS Inpatient Only list. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care following an elective right knee arthroplasty, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kyphoplasty procedure.

You asked the Plan to pre-approve the requested services. You say that you have fractured one of your discs
and you are in a lot of pain. The Plan denied your request. The Plan says you do not have documentation of an
osteoporotic fracture.

The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures are only covered under
certain medical indications.

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 requested services. Our physician
reviewer found that the records show a very mild L2 vertebral endplate fracture. There is minimal collapse of
the vertebra. There is no documentation of a trial of conservative measures to include bracing. There is no
documentation of a history of osteoporosis. Recent literature shows that kyphoplasty is not more effective than
sham therapy. Therefore, kyphoplasty is not medically needed in this case.

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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered under your Part B plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules.

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on August 4, 2020.
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 are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure codes Q0092, R0075, 71045, and 72220 have a PC/TC indicator of 3 and no professional component payment. 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 pay for the mobile x-ray services rendered on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair.
You asked the Plan to pre-approve a group 2 power wheelchair. You say that the requested group 2 power wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 2 power wheelchair.
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. 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 group 2 power wheelchair. Our reviewer says that the enrollee does not meet criteria for the requested group 2 power wheelchair. Our physician reviewer found the enrollee has a personal mobility deficit that impairs participation in MRADLs. The DME evaluation on 12/3/20 notes that the enrollee has a caregiver to assist with propulsion of a manual wheelchair for MRADLS and the caregiver assists with ADLS however the enrollee states currently in an appeal that he has no one to assist with propelling the manual wheelchair. The documentation does not support that the enrollee is able to safely maneuver the requested Group 2 power mobility device in the home therefore this request is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic
x-ray (D0330) provided on October 5, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you would
like these services to be covered. The Plan denied your request. The Plan says these services exceed the
maximum count allowed per period.
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, comprehensive oral evaluation
(D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record
shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on September
3, 2020, and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) benefits have been
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation
(D0150) and panoramic x-ray (D0330) provided on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that you recommend this minimally invasive procedure when conservative treatment has failed as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says that the requested service is experimental and investigational procedures are not covered by Medicare.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex spacer is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 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 the insertion of Vertiflex Superion device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray transportation provided on May 13, 2020.
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case place of service (POS) code 31 would indicate that the enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the portable x-ray transportation provided on May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts provided on October 29, 2020.
You asked the Plan to pay for the diagnostic casts. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered.
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 pay for the diagnostic casts provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 11, 2020.
You asked the Plan to pay for the physician's services. You say that your original referral request for coverage of the meeting with this provider was denied and your fast complaint via the Plan's portal did not work to get a referral approval for the meeting in time, so you took the meeting without prior authorization because time was of the essence and you needed to meet with the provider as soon as they said they were able because they are working with extremely cutting edge immunotherapy and you didn't want to forfeit a spot in their trial just because of a coverage issue that you could get resolved later. The Plan denied your request. The Plan says It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which our Plan authorizes use of out-of-network providers.
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 September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive respiratory disorder panel provided on June 17, 2020.
You asked the Plan to pay for the comprehensive respiratory disorder panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is a screening service.
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 comprehensive respiratory disorder panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient medical documentation to determine the medical reasonableness and necessity of the requested test. 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 comprehensive respiratory disorder panel have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive respiratory disorder panel provided on June 17, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Lupron depot injections (J9217).
You asked the Plan to pre-approve Lupron depot. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that the requested drug is prescribed for a medically unsupported off-label use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Lupron depot. Our reviewer says that the requested drug is reasonable and medically necessary for the enrollee. Our physician reviewer found that there is no evidence in the medical records of planned surgery or radiation. As the enrollee is not to get radiation or surgery, our reviewer deems the cancer unresectable and has determined that treatment as palliation with Lupron is supported by the Medicare-approved compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lupron depot have been met. Therefore, we decided that the Plan has to pre-approve Lupron depot injections (J9217).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says that
based on Medicare guidelines and the information we have about the enrollee's condition, the enrollee does not
meet all the requirements.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the medical documentation indicates that the enrollee has a history of R tonsillar
cancer status post radiation and chemotherapy, HTN, HLD, OSA, CAD, prostate cancer, and post&#8208; polio
syndrome who was admitted to the hospital on March 3, 2021, for hemoptysis. The enrollee's hospitalization
has been significant for open tracheotomy on March 3, 2021, healthcare associated pneumonia, hemorrhagic
shock, PEA arrest requiring intubation March 16, 2021, and embolization of pseudoaneurysm of external
carotid artery branch on March 18, 2021. The enrollee has been weaned from mechanical ventilation and
continues to require 8L O2. The enrollee requires tracheostomy care, physical therapy, occupational therapy,
speech therapy and tube feeds. There is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 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-approve LTACH services.