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

We decided that the Plan has to pre-approve a cardiac positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that a chemical stress test causes pain. 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 cardiac PET scan is covered when specific criteria are met. 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 submitted records show that you have a history of heart disease and high blood pressure. An echocardiogram on May 7, 2020 showed normal function. A clinic note dated June 2, 2020 documents palpitations, chest pain, and shortness of breath. You have known heart disease and chest pain. In this circumstance, further evaluation with a cardiac PET scan is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a cardiac positron emission tomography (PET) scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve timolol maleate.
You asked the Plan to pre-approve timolol maleate. The Plan denied your request. The Plan says this is not covered under the enrollee's part B plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve timolol maleate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399. You asked the Plan to pre-approve the compression stockings. You say that the enrollee has blood clot and on left leg. The Plan denied your request. The Plan says these stockings are not a covered benefit. The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 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 pre-approve compression stockings identified with code E1399.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 13, 2020.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Original Medicare is responsible for this claim.
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 13, 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 ambulance services provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve needle electromyography for guidance in conjunction with chemodenervation, Onabotulinumtoxina injections, and chemodenervation of one extremity to be rendered by an OON provider. You asked the Plan to pre-approve the needle electromyography for guidance in conjunction with chemodenervation, Onabotulinumtoxina injections, and chemodenervation of one extremity. The Plan denied your request. The Plan says you are OON with the enrollee's plan. The Plan also says that they do not see that the enrollee has needs that must be met by a provider that does not work with their plan. 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 needle electromyography for guidance in conjunction with chemodenervation, Onabotulinumtoxina injections, and chemodenervation of one extremity to be rendered by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation care provided to the enrollee on April 14, 2020. You asked the Plan to waive the copayment for acute inpatient rehabilitation care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2020 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 shows that the enrollee was admitted under acute inpatient status on April 12, 2020 and was discharged and readmitted under an acute inpatient rehabilitation unit on April 14, 2020. Since the enrollee was discharged from one level of care and readmitted to another, two separate copayments would apply. The enrollee's EOC states, "there is a $250 copayment per admission for each medically necessary inpatient stay. Additionally, if the member is discharged from one level of care and readmitted to another level of care, separate copays would apply." This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation care provided to the enrollee on April 14, 2020.
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 the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of a partial upper denture. 
 
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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a partial upper denture have not been met. Specifically, a partial upper denture was previously provided on August 17, 2017. Dentures (partial, full, immediate) are limited to one set every five years. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids charger provided on September 4, 2019 by a non-contracted provider.
You asked the Plan to pay for the hearing aids charger. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. We looked at the file, and the Plan's rules. Based on this information, the hearing aids charger denied correctly, as it is not listed as a covered benefit. Therefore, we decided that the Plan does not have to pay for hearing aids charger provided on September 4, 2019 by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a preventive visit (99397) provided on June 14, 2019. 
 
You asked the Plan to pay for the visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare cannot make payment for items and services furnished, paid for or authorized by governmental entities. 
 
The Plan must follow Medicare rules. Medicare rules say that if the individual elects to receive routine or nonemergency services through the VA system, the VA would be obligated by law to pay for those services and the MA organization would not be permitted to reimburse for such services under the same law. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Specifically, you received services at a Veterans Affairs facility. The MA organization is not permitted to reimburse for services furnished, paid for or authorized by government facilities. Therefore, we decided that the Plan does not have to pay for a preventive visit (99397) provided on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97163, 99348) provided on June 10, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not supported. 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 CPT Code Manual definition of code 97163 is "Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family". The CPT Code Manual Definition of code 99348 is "Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family". 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 services. Our reviewer says that the use of CPT codes 97163 and 99348 is not supported by the records provided on June 10, 2019. Our physician reviewer found that a Physical Therapist Assistant is not considered a qualified professional healthcare professional, and is unable to report 97163. CPT 99348 is a physician or qualified healthcare provider billing code. An RN is not considered a qualified healthcare professional for billing this code. It is also inappropriate to bill a evaluation and management code with a home visit note. 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 pay for the services (97163, 99348) provided on June 10, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI scan.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested MRI 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 scan. Our reviewer says that the documentation does support that the requested MRI is medically reasonable or necessary. Our physician reviewer found the enrollee diagnosed ANCA vasculitis and related inflammatory arthritis. The enrollee complained of bilateral foot pain and inflammatory arthritis was suspected. Prior to consideration for methotrexate treatment, the prescribing physician wants to confirm the diagnosis via MRI, which was requested. The enrollee was diagnosed with plantar fasciitis by the podiatrist. X-rays of the feet showed evidence of minimal degenerative changes without fracture or osseous erosions as expected. Physical findings included mild decreased range of motion of the feet with tenderness throughout MTPs and toes and some swollen toes. Due to the negative x-rays joint pains not characteristic of plantar fasciitis alone, persistent feet pain and a history of an inflammatory condition, inflammatory arthritis is a likely diagnosis but should be confirmed via MRI. Therefore, this request for MRI bilateral feet is supported and is considered medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI scan have been met. Therefore, we decided that the Plan has to pre-approve an MRI scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to return to being modified independent. The Plan denied your request. The Plan says you do not require intensive, complex interdisciplinary 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 physician reviewer found that you were admitted to the hospital with congest heart failure exacerbation, cellulitis, and a urinary tract infection. Your activity tolerance was fair to poor. You are generally medically stable. The documentation does not support that you have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician three times per week. While you may benefit from continuing physical and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rituximab infusions.
You asked the Plan to pre-approve the rituximab. You say that this medication is necessary to address worsening rheumatoid arthritis. The Plan denied your request. The Plan says there is no documentation that the preferred drugs, infliximab or Simponi Aria cannot be attempted.
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 the rituximab. Our reviewer says that the requested medication is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee is noted to have rheumatoid arthritis. A request has been made for Rituxan to treat the rheumatoid arthritis. The health plan requires that Remicade or Inflectra and Simponi Aria be used. There is no evidence that the enrollee is allergic to or intolerant of these other medications. There is no evidence that the enrollee has tried and not responded to these other medications. There is no documentation as to why these other medications would not be expected to be safe and effective for the enrollee. Therefore, the requested Rituxan is not shown to be currently medically necessary and reasonable.
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 rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve rituximab infusions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 27, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for podiatry services. You say that medically necessary services were rendered at a
time when an in-network podiatrist was not on-site to perform service. The Plan denied your request. The Plan
says the denial of payment for these services is correct, because this provider is out-of-network with the Plan
and authorization was not obtained.
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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 27, 2019 by
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an astigmatism-correcting intraocular lens (A-C IOL) to
be provided during an approved cataract surgery.
You asked the Plan to pre-approve the A-C IOL. You say that this should be approved as medically necessary.
The Plan denied your request. The Plan says Medicare does not make additional payment beyond the cost of a
standard IOL.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL.
While an A-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the astigmatismcorrecting
feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve an astigmatismcorrecting
intraocular lens (A-C IOL) to be provided during an approved cataract surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee is no longer making material gains.
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 pre-approve continued services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs. She had uncomplicated wound care to his heels and his sacrum. She was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a minimal to moderate assist level for functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.