Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a stress test.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a stress test is covered for specific indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you are currently asymptomatic but have moderate coronary artery disease (CAD) and have not had an evaluation in the past five years. A repeat stress test at this time is appropriate to make sure you do not have silent ischemia with exercise. The repeat stress test is medically necessary based on your history of known CAD with prior moderate/borderline significant anatomic disease.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a stress test.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

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 referral out-of-network for physical therapy.
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 care could be received in another setting.

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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental repairs (D5410, D5411, D5520).

You asked the Plan to pre-approve the dental repairs. You say that the repairs to a broke tooth are medically necessary. The Plan denied your request. The Plan says the requested dental services are not covered under your dental 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental repairs (D5410, D5411, D5520).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopantomgram.

You asked the Plan to pre-approve the x-ray. You say that that you fell while walking your friend's dog. You say that you knocked out your front tooth. You say that the injury was clearly not general preventive dental services that are not covered under original Medicare. You also say that this should be covered under your medical coverage. The Plan denied your request. The Plan says the service in this case is dental in nature. The Plan also says that the requested service relates solely to your tooth and is specifically excluded by your Medicare insurance coverage.

Medicare generally does not cover dental services. The Plan follows the same rule.

The service you are asking the Plan to pre-approve involves the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an orthopantomgram.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that you are not on insulin.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 monitor. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have difficulty using a glucometer due to blindness. You are losing sensation in your fingers due to the finger sticks. You should be given this monitor so you do not have to check the fingersticks so often. You are not able to check them well, and the finger pain may limit your ability to read Braille in the future. You are on a medication that can cause low blood glucose levels, and your control is sub-optimal.

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 monitor have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor.

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: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the JAK2 V617F testing. We decided that the Plan does not have to pay for the rest of the tests.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan says that the requested test is greater than the level of service warranted.

We decided that the Plan has to pay for JAK2 V617F.

The Plan follows Medicare rules. Medicare rules say that genetic testing of the JAK2 V617F mutation is medically necessary if the testing would impact medical management. 

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 for this testing. Our reviewer says that the requested testing is medically reasonable and necessary. Our physician reviewer found that the documentation shows a diagnosis of polycythemia, a myeloproliferative disorder. 

We looked at this physician's review, the file, and Medicare rules. The enrollee has a covered diagnosis for this test, and the results of the test will directly impact what other tests might be needed for this diagnosis. The testing will impact medical management. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for JAK2 V617F.

We also decided that the Plan does not have to pay for the rest of the tests.

The plan follows Medicare rules. Medicare rules say that CALR, MPL and JAK2-exon 12 testing can only be ordered if previous JAK2 V617F testing came back negative. 

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 for the rest of the testing. Our reviewer says that these tests are not yet medically reasonable or necessary. Our physician reviewer found that JAK2 exon 12, CALR, and MPL can only be ordered if JAK2 V617F testing is negative. These tests must be initially denied. 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 rest of the tests have not been met. Therefore, we decided that the Plan does not have to pay for the rest of the tests.

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).

You asked the Plan to pre-approve Gelsyn-3. You say that this drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria has not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Gelsyn-3. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the review indicates that the enrollee is a 76-year-old female with osteoarthritis of the knee. The Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says when a lift mechanism is approved for coverage, it does not include coverage for the chair itself.

The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.

Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. The plan has approved the seat lift mechanism itself. Our doctor found that the chair portion of the reclining chair with seat lift mechanism is not eligible for coverage as defined by Medicare criteria as the chair portion does not meet the definition of durable medical equipment. 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 a reclining chair.
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 need IRF care 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.   There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for intermittent skilled therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation doesn't support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. You are unable to ambulate at baseline. You appear to be at or near her prior level of function and can receive services at a lower 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.

You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity was not established by the records.

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 imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was appropriately evaluated per AHA/ACC guidelines regarding preoperative cardiac evaluations and testing before the planned non-cardiac surgery. Her history, physical exam and EKG coupled with the intermediate risk of the planned gynecologic surgery did not suggest any indications for preoperative ischemic testing with myocardial perfusion scintigraphy and she was appropriately recommended to go ahead with the planned gynecologic surgery. There are no other medical records provided of any change in her medical history, symptoms or signs since that time to suggest the need for an ischemic evaluation for coronary artery disease.

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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested fitness membership (S9970).

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the request for a membership with a fitness provider who is not part of the network is not a covered benefit under your contractual policy.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a fitness benefit only with the Plan select provider. 

The Plan's rules for coverage of fitness benefits have not been met because your request is for a membership with a fitness provider who is not part of the Plan's select network. Therefore, we decided that the Plan does not have to pre-approve the requested fitness membership (S9970).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve purchased of hearing aids from a non-plan-approved vendor.

You asked the Plan to pre-approve the hearing aids. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by contract providers.

You must use a plan-approved provider for hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve purchased of hearing aids from a non-plan-approved vendor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services (80053, 85025) to be performed at the tertiary hospital setting.

You asked the Plan to pre-approve the lab services. You say that your treating doctor is at the hospital and you need the lab tests performed at the tertiary facility. The Plan denied your request. The Plan says there are community providers that can render the lab services.

The Plan must follow Medicare rules. Medicare rules say that tertiary care requests will be sent to a community level provider when the service can be rendered by community level specialists.

We looked at the file and Medicare rules. The lab services are routine in nature. Community lab providers can provide this service. The plan has approved this service to be performed at a network lab facility. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pre-approve lab services (80053, 85025) to be performed at the tertiary hospital setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve a seat lift mechanism. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested seat lift mechanism.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.

We looked at the file and Medicare rules. The file shows that you are unable to ambulate once standing from a chair. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the lower extremity; without contrast material (73721).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that you have knee pain and underwent three weeks of lidocaine injections, used ice packs, heat packs, and topical creams for the pain. There was no clear documentation of recent attempts at physical therapy or other conservative treatments and there was no documentation of a physical finding on the knee that would warrant a more urgent MRI of the area. Therefore, this request will be considered not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the lower extremity; without contrast material (73721).
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 disagree with the denial. 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 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 medically necessary. Our physician reviewer found you were admitted to the hospital on April 21, 2021 with altered mental status, visual hallucinations, and irregular heartbeat. The complexity of your nursing, medical and rehabilitation needs does not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. 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.