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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin/wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can allow for meaningful and measurable gains within a reasonable period. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this would provide significant clinical and quality of life benefits. The Plan denied your request. The Plan says this is experimental.
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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer remains experimental. More research is needed to show it is safe and effective. 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. Medicare guidelines say that in order for a CGM to be covered, all of
the above criteria must be met. The enrollee must have been using a BGM and performing frequent (four or
more times a day) testing. Medicare also says therapeutic CGMs are covered when the enrollee is insulintreated
with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous
insulin infusion (CSII) pump. In this case, the file shows that the enrollee does not perform four or more blood
glucose testing per day and that the enrollee is not insulin treated with multiple (three or more) daily injections.
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric hospital for the enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a non-acute long term psychiatric care setting. 
 
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided for this admission, thge enrollee does not meet the criteria for continued acute inpatient mental health treatment from April 24, 2020 forward. The enrollee was not shown to be a danger to herself or others. The enrollee was not showing any auditory or visual hallucinations. The enrollee was cooperative and compliant with treatment, while not showing any threats to 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric hospital for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic addition, endoskeletal system, above knee,
flexible protective outer surface covering system.
You asked the Plan to pre-approve addition, endoskeletal system, above knee, flexible protective outer surface
covering system (L5964). You say that you need the prosthetic additions. The Plan denied your request. The
Plan says there is no supporting documentation indicating you are exposed to a harsh wet environment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The record does not show that you encounter harsh environmental
situation where it is necessary to protect the lower limb beyond the protection from the included cover. Based
on this information, we decided that Medicare rules for coverage of addition, endoskeletal system, above knee,
flexible protective outer surface covering system (L5964) have not been met. Therefore, we decided that the
Plan does not have to pre-approve prosthetic addition, endoskeletal system, above knee, flexible protective
outer surface covering system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance, osseous surgery, and bone
replacement graft provided on October 28, 2019 and December 19, 2019 by an OON provider.
You asked the Plan to pay for the periodontal maintenance, osseous surgery, and bone replacement graft. You
say that these services were provided in 2019. You also say that you would like an explanation for the
reference to the $100 yearly plan deductible as of January 2020. The Plan denied your request. The Plan says
the treating provider is OON. The Plan also says that this provider is allowed to bill you the difference of the
allowed amount and their billed amount because they do not participate with the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference
between the billed amount and allowed amount when the services are received OON. Therefore, we decided
that the Plan does not have to pay for the periodontal maintenance, osseous surgery, and bone replacement graft
provided on October 28, 2019 and December 19, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living.The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare.   The requested limb orthosis continues to be denied because of insufficient evidence of its effectiveness.Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan
denied your request. The Plan says this is experimental.
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 radiofrequency ablation. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the diagnostic lateral branch provided minimal relief. The performance of
radiofrequency ablation is therefore not medically necessary. Furthermore, this procedure is considered
experimental/ investigational because of the wide variation in efficacy reported in the peer reviewed literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation (64625).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided October 1, 2019 to October 8, 2019.You asked the Plan to pay forthe SNF services. You say that the rev code used is 0120 which has been the same rev code used on prior claims  that were paid. The only thing that has changed is the new PDPM HCPC codes are now being used instead of rugs.The Plan denied your request. The Plan says the claims must be billed with a valid 0022 Rec Code along with PDPM code effective October 1, 2019. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the claims must be billed with a valid 0022 Rec Code along with PDPM code. 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 forthe skilled nursing facility (SNF) services provided October 1, 2019 to October 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for home health care services provided on January 3, 2019 to January 31, 2019.You asked the Plan to waive the deductible for the home health services. You say that you had already met your deductible amount. You say you would like the claim reprocessed.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 a $500 deductible that applies towards each in-network home health visit. The home health services you asked the Plan to waive the deductible for falls within the "Home health agency care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards each in-network home health visit. This cost sharing is a contractual obligation that had not been met at the time the home health services were received on January 3, 2019 to January 31, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the home health care services provided on January 3, 2019 to January 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care provided to the enrollee starting on June 11,2020.You asked the Plan to pre-approve the acute inpatient hospital care. You say that this care is medically necessary.The Plan denied your request. The Plan says that inpatient services are not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would not span two midnights. Our physician reviewer found that the enrollee's condition does not meet criteria for inpatient hospital 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 the acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care provided to the enrollee starting on June 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean MRI with spectroscopy.You asked the Plan to pre-approvean MRI with spectroscopy. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the services are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that items and servicesthat are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare considers MRI with spectroscopy an investigational procedure and issued a national noncoverage determination for all indications of MRI's with spectroscopy. Based on this information, we decided that Medicare rules for coverage of an MRI with spectroscopy have not been met.Therefore, we decided that the Plan does not have to pre-approvean MRI with spectroscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gastrointestinal (GI) pathogen testing provided on December 12, 2019.
You asked the Plan to pay for genetic testing. You say that you are an independent laboratory and this test was provided according to the referring provider's request. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Without this information, you have not supported that this lab test was ordered and performed for covered indications. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for gastrointestinal (GI) pathogen testing provided on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Levofloxacin tablet and Prednisone tablets provided on May 8, 2019.
You asked the Plan to pay for the Levofloxacin and Prednisone. You say that you do not feel that these drugs were self-administered because they were given to you in the emergency room. The Plan denied your request. The Plan says these drugs are self-administered drugs. The Plan also says these drugs are not Part B covered.
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 pay for the Levofloxacin tablet and Prednisone tablets provided on May 8, 2019.
Benefits for the Levofloxacin and Prednisone 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the supplies were requested at a regular
doctor's visit and the supplies should be covered for you. The Plan denied your request. The Plan says these
items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta (J3304). You asked the Plan to pre-approve Zilretta. You say that this is medically necessary. The Plan denied your request. The Plan says Zilretta is not intended for repeat administration.
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 Zilretta. Our reviewer says that the use of Zilretta is not supported in this case. Our physician reviewer found Zilretta is not intended for repeat administration; safety and efficacy of repeat administration has not been established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 31, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee walker.
You asked the Plan to pre-approve a knee walker (E0118). You say that you need a knee walker to get around your house. The Plan denied your request. The Plan says a knee walker is not a covered benefit under your Medicare benefit plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Knee scooters are statutorily excluded by Medicare. Based on this information, we decided that Medicare rules for coverage of a knee walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are scared to shower because of the pain
issues you experience from the waist down. You say that someone has to be with you to shower or bathe
because your legs are strained which causes instability and pain. You stated that you need the requested
equipment that your doctor ordered because you are a fall risk. You say that it is possible that you could slip or
fall and end up in the hospital. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.