Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on April 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 pay forthe drug testing services provided on April 18, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided thatthe Plan has to pre-approveacupuncture therapy.You asked the Plan to pre-approveacupuncture therapy. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 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 acupuncture therapy. Our reviewer says that the services are medically necessary. Our physician reviewer found there was chronic low back pain reported which was treated with pain medications. It appears that based on the provided documentation,the joint pain in the lower back and sacroiliac areas is causing chronic low back pain and meets criteria for a trial of acupuncture.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acupuncture therapy have been met.Therefore, we decided that the Plan has to pre-approveacupuncture therapy.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 pre-approvea continuous glucose monitor.You asked the Plan to pre-approvea continuous glucose monitor. You say that you are blind and have difficulty using a traditional meter.The Plan denied your request. The Plan saysyour provider did not submit documentation that you are insulin treated and testing four or more times a day.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 shows youare not insulin treated so you do not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a interlaminar/interspinousprocess stabilization/distraction device (22869).You asked the Plan to pre-approve insertion of a interlaminar/interspinous process stabilization/distraction device. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 insertion of a interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of a interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on January 13, 2020.
You asked the Plan to pay for the services. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says fee-for-service Medicare covers attending all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 1, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The patient was medically stable with no evidence of need for supervision by physical medicine and rehab Physician or need for acute rehab nursing care. Functionally given her current level, the enrollee needs physical therapy and occupational therapy but does not require IRF level of therapies. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation therapy and brachytherapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is not outside the standard care, and this has been requested in the past with no issues. The Plan denied your request. The Plan says that the enrollee was already treated with the standard of care for favorable intermediate prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's treatment does not follow the recommendations of NCCN guidelines, though is consistent with AUA/ASTRO/SUO Guidelines and American Society of Clinical Oncology/Cancer Care Ontario Joint Guidelines. A patient with Gleason 7 disease and no other risk factors would have been eligible for the ASCENDE-RT trial, which serves as a basis to consider combined treatment as an accepted standard. Clearly for 'unfavorable intermediate risk" patients this is less controversial. Complicating the review for this case is the fact that this enrollee received a sub-therapeutic brachytherapy dose (i.e. less than would be given with brachytherapy alone) such that to adequately treat him, a course of IMRT is needed. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve intensity modulated radiation therapy and brachytherapy for the enrollee.
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 the compression stockings identified with code A6533 that were issued on January 13, 2020.
You asked the Plan to pay for the compression stockings. You say that the claim should be paid. The Plan denied your request. The Plan says the stockings are noncovered because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are at risk for falls and it could result in permanent damage. The Plan denied your request. The Plan says the services are 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 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 services are not medically necessary. Our physician reviewer found the records show that you had a primary care physician office visit on July 22, 2020 due to increased unsteadiness and several recent falls. You use a rolling walker with moderate assistance and need assistance for activities of daily living and transfers. The complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve(L1833, L2397) provided to the enrollee on August 19, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOpdivo and Yervoy for the enrollee.You asked the Plan to pre-approveOpdivo and Yervoy. You say that these drugs are medically necessary for the enrollee.The Plan denied your request. The Plan says that the use of these drugs is not supported.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Opdivo and Yervoy. Our reviewer says that Opdivo and Yervoy are not medically reasonable and necessary for the enrollee in this case. Opdivo and Yervoy are not FDA-approved for the enrollee's diagnosis. This use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Opdivo and Yervoy.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of Opdivo and Yervoy have not been met.Therefore, we decided that the Plan does not have to pre-approveOpdivo and Yervoy for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the lumbar spine.
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the requested MRI of the lumbar spine is medically necessary. The Plan denied your request. The Plan says that the requested MRI of the lumbar spine is not medically necessary.
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 an MRI of the lumbar spine. Our reviewer says that the requested MRI of the lumbar spine is medically necessary. Our physician reviewer found this enrollee presents with a history of chronic low back pain. He reports progressively worsening back pain, difficulty ambulating, and neuromuscular weakness over the last 6 months. Significant functional loss in ambulatory tolerance and ability to perform activities of daily living over the last month is reported. Signs and symptoms are consistent with neurogenic claudication. Clinical exam findings have documented positive nerve tension signs and reflex changes. There is radiographic evidence of mild to moderate multilevel lumbar degenerative changes. He has failed to improve over the past 6 months with physician-directed conservative treatment, including activity modification, oral and topical analgesics, heat, and initial of physical therapy. Under consideration is a request for lumbar spine MRI. Current evidence based medical guidelines and literature recommends imaging after a trial of treatment is recommended for patients who have minor risk factors for cancer, inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. This enrollee is additionally status post prior lumbar surgery. Given the reported severity of symptoms, marked functional limitations, and progressive neuromuscular weakness, proceeding with an MRI to determine the treatment plan, including plausible invasive intervention, is reasonable. Therefore, the requested lumbar spine MRI is medically reasonable and necessary for the enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve an MRI of the lumbar spine.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental core buildup for teeth #28 and 29.
You asked the Plan to pre-approve the core buildup. You say that the enrollee needs treatment to increase his overall dental health. The Plan denied your request. The Plan says the service is not a covered benefit.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core buildup for teeth #28 and 29.
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 IRF admission 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 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with severe chronic obstructive pulmonary disease and frequent hospital admissions. She has required mechanical ventilation. Currently, is on NIPPV and has undergone aggressive pulmonary care and diuresis. Hemodynamics are stable, but she fatigues easily and has poor endurance. She desaturates with activity, and is on 4-litres O2 currently. Now, is mostly contact guard assist for care. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound/skin and O2 care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly standby/contact guard assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive ventilator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a non-invasive ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met in network.
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 a non-invasive ventilator to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from July 30, 2019 through September 19, 2019.You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you were at the facility from July 30, 2019, to September 19, 2019. The first 20 days had no cost share.Starting the 21st day you had a cost share of $150.00 per day.  You remained at the facility for 32 more days. You accumulated a cost share of $1,860 for thirteen days. At this point, you reached your 2019 out-of-pocket maximum. 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 SNF care from July 30, 2019 through September 19, 2019.