Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient surgery provided on January 21, 2021.
You asked the Plan to waive the deductible for outpatient surgery. You say that you think this charge is outrageous. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible for outpatient surgery at an outpatient hospital. At the time this claim had been processed, $98.22 of the $750 deductible had been met. The allowed amount of this claim is $534.06, resulting in a deductible obligation of $534.06. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible for Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. This cost sharing is a contractual obligation that had not been met at the time outpatient surgery was received on January 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient surgery provided on January 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen and pelvis (74177).
You asked the Plan to pre-approve CT scan of the abdomen and pelvis. You say that this requested service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says an ultrasound would be reasonable and necessary before the requested CT scan.
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 CT scan of the abdomen and pelvis. Our reviewer says that the requested CT scan is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 69-year-old female with complaints of nausea and vomiting for one month. In this case, the medical records provided do not support the use of a CT scan at this time. There has not been any workup done of the enrollee's symptoms of nausea and vomiting and a CT scan would not be first line evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen and pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because you are in extreme pain and the shots have not provided relief. The Plan denied your request. The Plan says there are in-network providers available to render the requested MRI.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the MRI to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
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 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will 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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The patient has right shoulder pain related to severe glenohumeral osteoarthritis and has failed conservative treatment. The enrollee is receiving an elective reverse total shoulder arthroplasty with tenodesis of long tendon of biceps and capsular contracture release. The patient is medically stable at the time of admission, and there is no expectation that the patient would have a difficult or complicated recovery. It is not expected, based on the provided records, that the patient would require hospitalization that would likely cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occipital nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational, due to a lack of scientific evidence regarding the effectiveness of this for migraines.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the current expert consensus of the American Headache Society (AHS) the use of peripheral nerve blocks in headache disorders is noted to be experimental. 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve an occipital nerve block for the enrollee.
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 you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with home health care, or in a long-term care setting.
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 member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 22 PT visits.
You asked the Plan to pre-approve additional PT visits. You say that you continue to have pain in your lower back and legs that limits your ability to perform activities of daily living. The Plan denied your request. The Plan says an additional 22 PT visits are not reasonable and 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 an additional 22 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 your condition beyond what was approved by the health Plan. You have had extensive prior therapy and the records do not demonstrate that the 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 beyond what was approved by the health Plan. You have been instructed in a home exercise program and you were authorized additional sessions to ensure competence in a 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 your 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 an additional 22 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 22 PT visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0425, A0428) service provided on September 30, 2020.
You asked the Plan to pay for the non-emergency ambulance transportation (A0425, A0428) service. You say that you needed to go to the hospital for a bedsore that you believed needed to be cared for right away. You say that you had been without a care giver for two weeks so there was no one to take you and that is why you called an ambulance. The Plan denied your request. The Plan says the non-emergency ambulance service was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergency ambulance transportation (A0425, A0428) service. Our reviewer says that the requested non-emergency ambulance
transportation (A0425, A0428) service was not medically reasonable and necessary. Our physician reviewer found that in this case, you were transported non-emergently by a basic life support unit. You felt weak and thought that you had a bedsore. The provided record indicates that you could have been transported by a lower-level transportation service. The elements of the coverage rule are not satisfied. The requested service is not 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 the non-emergency ambulance transportation (A0425, A0428) service have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0425, A0428) service provided on September 30, 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 needs IRF care in order to improve strength, endurance, activities of daily living, and mobility. You say that daily medical oversight is required for treatment of the enrollee's medical needs. The Plan denied your request. The Plan says IRF care is not medically necessary.
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 coronary artery bypass grafting with subsequent stroke and encephalopathy. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Euflexxa. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has osteoarthritis of the hip. Viscosupplementation with hyaluronic acid seems to be a valuable technique for the management of painful osteoarthritis of the hip that may delay the need for surgical intervention. Further prospective randomized placebo-controlled studies are necessary to draw definite conclusions. Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is a non-formulary product.
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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested test strips. The requested Contour Next test strip is not a formulary product. The review has determined that there is no specific medical reason to use the non preferred brand 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Guardant360 laboratory test provided on September 21, 2020.
You asked the Plan to pay for the Guardant360 laboratory test. You say that the Plan should pay this claim. The Plan denied your request. The Plan says that available studies do not clearly show that the test results when used to influence treatment decision-making result in improved patient outcomes.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the Guardant360 laboratory test. Our reviewer says that the test was considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided states that the prescriber is evaluating the enrollee's specific condition for an actionable mutation that would alter therapy. The requested service not a screening test. The elements of the coverage criteria are satisfied. The requested service is 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 the Guardant360 laboratory test have been met. Therefore, we decided that the Plan has to pay for the Guardant360 laboratory test provided on September 21, 2020.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional outpatient physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says four visits can be approved to intensely focus on finalizing a home exercise program.
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 the additional 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 there have been thirty six visits so far. The enrollee has stated that she has not been performing all her exercises at home every day. The plan approved 4 additional outpatient PT visits to intensely focus on finalizing a home exercise program, and to educate and reinforce the importance of continued and consistent adherence to the program. The documentation does not support that eight additional outpatient PT visits are required to safely and effectively provide treatment. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional outpatient physical therapy visits for the enrollee.