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

We decided that the Plan does not have to pre-approve a facet joint block.
You asked the Plan to pre-approve a facet joint block. You say that the requested facet joint block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested facet joint block.
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 facet joint block. Our reviewer says that the enrollee does not meet criteria for the requested facet joint block. Our physician reviewer found the enrollee has chronic neck pain/cervical facet syndrome. He had diagnostic cervical medial branch blocks (MBBs) performed and achieved 70% pain relief for one week. The request is to repeat the blocks. The LCD requires documentation of 80% pain relief. The injections did not meet this level of pain relief and therefore, the request is deemed 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 a facet joint block have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint block.
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 the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 the enrollee was admitted to acute care on 6/6/21 after a ground level fall resulting in a left humeral neck fracture treated non-operatively with a sling. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a contact guard/minimal assist to stand by assist level with functional mobility including gait to 35 feet with a hemi-walker. The enrollee required varying assist with activities of daily living. She remained non-weight bearing to her left upper extremity. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the durable medical equipment (DME) you received on January 7, 2021.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.
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 20% coinsurance for durable medical equipment.
Review of the file shows that you were provided DME on January 7, 2021. You have been asked to pay a 20% coinsurance for the DME, totaling $200. 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 durable medical equipment (DME) you received on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care services provided on January 31, 2021 by an out of network provider.
You asked the Plan to pay for chronic care services (99491). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 chronic care services provided on January 31, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 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 testing is 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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve radiation oncology services. You say that this request is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the requested services.
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 radiation oncology services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.

You asked the Plan to pre-approve Entresto. 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 a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluticasone propionate nasal suspension (Flonase).
You asked the Plan to pre-approve Flonase. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Flonase is
an OTC item. Therefore, we decided that the Plan does not have to pre-approve fluticasone propionate nasal
suspension (Flonase).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on January 22, 2021.

You asked the Plan to waive the copayment for these services. You say that you were not seen by a doctor. The Plan denied your request. The Plan says the copayment was 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 a $90 copayment for each Medicare-covered emergency room visit.

Review of the file shows that you received ER services on January 22, 2021. You have been asked to pay a $90 copayment for these services. These services fall within the Medicare-covered emergency room visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on September 13, 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 there is no valid physician order.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.

We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 neuromuscular stimulator rendered on September 13, 2020.
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 the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 the enrollee is with subarachnoid
hemorrhage/traumatic brain injury and thoracic spinal fracture, currently in IRF. From a nursing perspective,
the enrollee received oral medications and IV antibiotics. The enrollee had stable vital signs. She was treated
for pain. She had a back wound treated with a wound vac with MRI fluid collection in the laminectomy bed.
Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational
therapy in the acute hospital. The enrollee was at a stand by assist to moderate assist level with functional
mobility including gait to 5 feet with a rolling walker. The enrollee required varying assist with activities of
daily living.

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amyotrophic lateral sclerosis (ALS) genetic panel testing.

You asked the Plan to pre-approve ALS genetic panel testing. You say that due to the enrollee's condition and family history it will be important to test for this gene mutation. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this is not a covered test, there is no indication that the results of this testing will change the enrollee's management or improve outcomes, and therefore this testing is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Medicare covers certain molecular diagnostic tests that have undergone evaluation and approved by the MolDX contractor. The amyotrophic lateral sclerosis gene panel, including the C9orf72 gene, has not been approved for coverage. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ALS genetic panel testing have not been met. Therefore, we decided that the Plan does not have to pre-approve amyotrophic lateral sclerosis (ALS) genetic panel testing.
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. 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 to an acute care hospital for lumbar fusion. Medical conditions 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. The patient 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. 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: 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 SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the SNF care benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from December 29, 2020, to May 18, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 will benefit from IRF to optimize function prior to returning home. The Plan denied your request. The Plan says an IRF admission is considered 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 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. The patient 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 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 confusion and pneumonia. 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, in 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. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 25, 2021.
You asked the Plan to pay for the ambulance services. You say that The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 25, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transport brackets (K0108) and a power seat elevation
system (E2300).

You asked the Plan to pre-approve transport brackets and a power seat elevation system. You say that you
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says transport brackets
are considered a convenience item and are not covered by Medicare or the Plan. The Plan says that a power
seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The transport brackets at issue in this appeal do not serve a purpose that is primarily medical in nature. This
item is available to the general public and would be helpful even to those who are not sick or injured. Medicare
specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the
Plan does not have to pre-approve transport brackets (K0108) and a power seat elevation system (E2300).