Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you have lost all your muscle strength.The Plan denied your request. The Plan says you do not require and are not able to tolerate three hours of daily intensive therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply therelevant 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require skilled physical therapy and occupational therapy, based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 23, 2018 to August 7, 2018.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 23, 2018 to August 7, 2018.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for a preventive medicine evaluation (routine physical) provided on October 17, 2019.
You asked the Plan to hold you harmless for routine physical. You say that you did not have a previous physical in 2019. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because only 1 annual physical per calendar year is covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records to support that an annual physical examination was performed on either October 17, 2019 or any prior date in 2019. You say that you did not receive an annual physical exam in 2019 prior to this date of service. Without supporting documentation, the Plan has not shown that the benefit for annual physical examination was exhausted at the time you received this service. Therefore, the Plan has not shown that its decision to hold you liable for this denial of payment is correct or justified according to Medicare rules or the Plan contract. This service was billed by an in-network provider, so the Plan should ensure that you are not held liable for the denied amount to the in-network provider. Therefore, we decided that the Plan has to hold you harmless for a preventive medicine evaluation (routine physical) provided on October 17, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelongterm acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that long term acute care hospital services are medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of a long term acute care hospital admission.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 that you are currently undergoing treatment at an acute care hospital (ACH), having initially been admitted with an obstructed foley catheter. You suffered cardiac arrest and weretransiently intubated/ventilated. Additionally, you havebeen receiving intermittent hemodialysis. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring youto the LTACH. Youcan remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term careneeds.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong termacute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ZILRETTA injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the FDA does not recommend repeat administration of ZILRETTA.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee received ZILRETTA injections of bilateral knees on 12/19/2018. The provider is currently recommending a repeat of ZILRETTA injections to both knees. Per the FDA approved prescribing information, ZILRETTA is indicated for the management of knee pain due to osteoarthritis and is not intended for repeat administration. It can only be used once per knee per lifetime. Based on a review of the information submitted, this patient has already received ZILRETTA injections. The authorization for repeat administration of ZILRETTA cannot be provided. The documentation does not support that the service at issue is medically reasonable or necessary for this enrollee. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a ZILRETTA injection for the enrollee.
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 enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.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 enrollee is currently undergoing treatment at an ACH for pneumonia and respiratory failure in the setting of ILD/CREST syndrome. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 31, 2018.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on August 31, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided January 3, 2020 to January 6, 2020.You asked the Plan to waive the coinsurance for inpatient hospital services. You say that the coinsurance should be waived.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 Inpatient Care. You have been asked to pay a 20% coinsurance for inpatient hospital services. Inpatient hospital services fall within the Inpatient Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided January 3, 2020 to January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says picture studies are not supported to guide this type of treatment during the first phase.
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 services. Our reviewer says that the
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer
found IGRT for whole breast radiation is an accepted standard for exceptional circumstances such as difficult
patient set-up, prior radiation necessitating more accurate localization, abutment of the field against a critical
organ (such as heart in left sided breast cancers). Another rationale would be initial set-up errors necessitating
serial imaging (https://www.ncbi.nlm.nih.gov/pubmed/23443609). However, there is no plausible rationale for
the need of IGRT for this enrollee. This would not be furnished in accordance with accepted standards outside
of special/exceptional circumstances - which the case records do not justify.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve image-guided radiation therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) and administration (90471) provided on  December 27, 2019.You asked the Plan to pay fora shingles vaccine and administration. You say that you were told this was covered.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) and administration (90471) provided on  December 27, 2019.Benefits for a shingles vaccine and administration may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on March 10, 2020.You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the referring physician in this case are not networkproviderswith the Plan. The Plan did not pre-approve the drug testing. 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 drug testing provided on March 10, 2020.
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 procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found both percutaneous lumbar decompression and the vertifex spacer device are experimental for use at this time. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveophthalmology services to be provided by a tertiary provider.You asked the Plan to pre-approvetertiary services. You say that the provider performed surgery on your other eye.The Plan denied your request. The Plan says the requested services do not need a higher level of care.Medicare rules say that plans can require enrollees to get care from network providers. The requested provider in this case is a tertiary provider. There is no indication that the requested services cannot be provided within the preferred network. There is insufficient evidence to show that you need an advanced level of care. 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-approveophthalmology services to be provided by a tertiary provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the breast for the enrollee.You asked the Plan to pre-approve the MRI. You say that this is medically necessary to provide a more accurate picture of whether you are cancer free.The Plan denied your request. The Plan says while breast MRI has been shown to have a marginally higher breast cancer detection rate than mammography alone, it has not been shown to result in a higher survival rate for women with prior history of breast cancer.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found unfortunately, there is no mammogram report included in the records submitted. Indeed, if the enrollee has underlying heterogeneously or extremely dense tissue on mammography there is adequate medical literature to support screening MRI of the breasts yearly together with annual mammography alternating every 6 months, however there is no way to substantiate the density of the patient's breast tissue without viewing the actual prior mammography reports.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve MRI of the breast for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approve the medical services to be provided by an OON provider. You say that you have an established history with this provider and do not want to have to switch.The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.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 medical services 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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin 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 enrollee is currently undergoing treatment at an acute care hospital for complications following a recent bladder rupture. The enrollee underwent abscess drainage and received antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.