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

We decided that the Plan does not have to pre-approve a hip tenotomy.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
clinical effectiveness has not been demonstrated.
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 requested services. Our physician
reviewer found that the enrollee has tendinopathy of the gluteus minimus. She is taking Lyrica and Celebrex
for pain. She declined further physical therapy as it has not been helpful. She also uses ice. The literature does
not support percutaneous tenotomy and the injection of platelet-rich plasma is considered experimental/
investigational. Therefore, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a hip tenotomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization.
You asked the Plan to pre-approve the inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary.
Our physician reviewer found it is not expected you will improve in a reasonable period of time for the dates in
question as you do not have suicidal or homicidal ideation noted and you denied any auditory or visual
hallucinations.
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 inpatient psychiatric hospitalization have not been met. Specifically, you are
compliant with treatment and do not show any acute threats to safety. It does not appear medically necessary
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of
care. Therefore, we decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal surgery (22869, 22870).
You asked the Plan to pre-approve the spinal surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 pre-approve the spinal surgery. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous implant used for the fusion is experimental. More research is needed to show safety and efficacy of interspinous implants.
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 spinal surgery have not been met. Specifically, more research is needed to show safety and efficacy of interspinous implants, and therefore, is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the spinal surgery (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that you are in severe pain. The Plan denied your request. The Plan says you have had only one set of diagnostic medial branch blocks.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is 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 you have a history of lumbar spondylosis with facet-mediated pain. Initial diagnostic medical branch blocks (MBBs) at L4-5, L5-S1 were completed on July 22, 2021. In this case, you had only one set of diagnostic MBBs and have not undergone a prior RFA procedure to the same level. The records do not show that you have met the coverage criteria. Therefore, the requested treatment is not medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve lumbar radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected you will improve in a reasonable period of time beyond the dates in question as you are not showing any dangerousness to self or others, auditory or visual hallucinations and you are without aggressive behaviors while not showing any acute threats of safety. 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 psychiatric hospitalization have not been met. Specifically, It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair sip and puff system.
You asked the Plan to pre-approve power wheelchair sip and puff system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item 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 pre-approve power wheelchair sip and puff system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of Duchenne muscular dystrophy. While the enrollee does have a diagnosis/condition that could meet criteria for the requested item in this case, there are no medical records a diagnosis of Duchenne muscular dystrophy. Therefore, the enrollee does not meet criteria for the requested item 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 power wheelchair sip and puff system have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair sip and puff system.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of abdomen and pelvis (74177) and a CT scan of the chest (71260).
You asked the Plan to pre-approve the CT scans. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.
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 scans. Our reviewer says that the service is medically necessary. Our physician reviewer found this patient has a lung cancer that is PD-L1 positive and thus is eligible to be enrolled in a clinical trial of chemoimmunotherapy. The managing oncologist needs to have a baseline dedicated CT of the chest, abdomen and pelvis prior to beginning this new therapy in order to assess treatment success/failure. 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 scans have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of abdomen and pelvis (74177) and a CT scan of the chest (71260).
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 admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you are an 88-year-old female with
dementia, atrial fibrillation and hypertension. While there are identifiable skilled therapy service needs, there
are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy
services on a daily basis. Finally, you do not meet severity of illness or intensity of service criteria for an
inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on March 29, 2021.
You asked the Plan to pay for a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning. You say that you have been going to this office for years and do not want to change providers. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by an out-of-network dentist on April 5, 2021.
You asked the Plan to pay for dental services. You say that this provider was on the list of participating dentists in your area, and you were not prepared to pay this amount. The Plan denied your request. The Plan says the denial of additional payment for these services is correct, because you have been reimbursed 50% of the non-participating allowed amount for these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers out-of-network dental services. Your contract with the Plan clearly discloses that you must pay for out-of-network dental services up front and be reimbursed 50% of the non-participating rate. The allowed amount of this claim is $140, resulting in a reimbursement amount of $70.
We looked at this the file, the Plan's rules and Medicare rules. The Plan has reimbursed you the correct amount
based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for dental
services provided by an out-of-network dentist on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Foresee Home eye monitoring device.
You asked the Plan to pre-approve Foresee Home eye monitoring device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device 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 pre-approve Foresee Home eye monitoring device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has non-exudative age-related macular degeneration. The record submitted does not contain medical records supportive of the requested service. The provided records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's specific clinical condition. Therefore, the enrollee does not meet criteria for the requested device.
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L34555 to support their denial. However, LCD L34555 is not valid for the enrollee's home state of Kentucky. Therefore, we are unable to use LCD L34555 to substantiate our decision. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Foresee Home eye monitoring device have not been met. Therefore, we decided that the Plan does not have to pre-approve Foresee Home eye monitoring device.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that the patient was admitted for right below the knee amputation because of peripheral vascular disease. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion. there is not a reasonable expectation that this patient 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: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on February 2, 2021.
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for enrollees with suspected or documented cardiovascular disease.
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 follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on February 2, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator unit provided on October 5,
2020.
You asked the Plan to pay for neuromuscular stimulator. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the
documentation submitted does not include proof of delivery for the item billed.
The Plan must follow Medicare rules. Medicare rules say that a health plan may require proof of delivery for
items billed on a claim.
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of
delivery for the specific item billed on this claim. Based on this information, we decided that Medicare rules
for coverage of neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have
to pay for a neuromuscular stimulator unit provided on October 5, 2020.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 indicating medical necessity for admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the LTACH that are not available at the acute care hospital where she 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says the Vertiflex procedure is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure