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

We decided that the Plan has to pre-approve MRI of the leg for the enrollee.You asked the Plan to pre-approve the MRI. You say that this is medically necessary for severe pain.The Plan denied your request. The Plan says that no hip exam or PT is documented.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has multiple indications for MRI of the right hip including SLE and RA as well as steroid usage. She completed a course of PT and had a telemedicine conference after same with requesting office which satisfies the requirement for followup evaluation after the PT completion. Scan is indicated and all necessary medical necessity criteria are met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met.Therefore, we decided that the Plan has to pre-approve MRI of the leg 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora home rest visit provided to the enrollee on December 31, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless pre-authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 a home rest visit provided to the enrollee on December 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you previously had a stent put in and have had fractured ribs due to being hit by a car. You stated that you are in constant pain. You say that you have had a heart attack before and you wanted to make sure that you were not having another one.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided from December 17, 2019 to December 20, 2019. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges because you feel that you were admitted inpatient. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for emergency care.  
 
The medical records show that you were not admitted inpatient after and ER visit from December 17, 2019 to December 20, 2019. Therefore, you are responsible to pay the $100 copayment.  
 
You have been asked to pay a $100 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided from December 17, 2019 to December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelumbar laminectomy for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a physical exam. There is no correlation with the physical exam. The criteria for surgery is not met.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelumbar laminectomy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of bedside commode chair with fixed arms (E0163). You asked the Plan to pre-approve the commode chair. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the medical records do not support that the enrollee meets the criteria listed in the LCD. 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 commode chair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the enrollee does not meet the requirements listed in the LCD for Medicare coverage. There is no documentation that the enrollee is confined to a single room or confined to one level of the home environment and there is no toilet on that level or confined to the home and there are no toilet facilities in the home. 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 commode chair have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement of bedside commode chair with fixed arms (E0163).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's physicians have determined that the enrollee cannot be adequately care for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says that records show the enrollee does not have to see the doctor daily, have a complex illness requiring continued hospital care, need specialized nursing care, or an expectation she will need acute care for more than 25 days.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee needs to continue on this medication. The Plan denied your request. The Plan says this medication has been approved under the enrollee's Part D plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Prolia (J0897).  
 
Benefits for Prolia 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 red corvette drive wheel accent color, wheelchair
component or accessory (K0108).
You asked the Plan to pre-approve red corvette drive wheel accent color. You say that please review the
attached medical documentation to support the need of the custom medical equipment being requested. The
Plan denied your request. The Plan says this item is not primarily medical in nature and cannot be covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve red corvette drive wheel accent color, wheelchair
component or accessory (K0108).
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 there is no valid national or local coverage determination
for this type of orthosis.
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. 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. Based on this information, we decided that Medicare rules for coverage of a powered upper
extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does
not have to pre-approve a powered upper extremity range of motion assist device.
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 physical, speech and occupational therapy. The Plan denied your request. The Plan says that you do not meet criteria for acute inpatient rehabilitation 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program. There is no indication for the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 12, 2018 by an
out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider 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 December 12,
2018 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of the complete maxillary denture provided on November 8, 2019. 
 
You asked the Plan to pay for the reline of the complete maxillary denture. You say that this procedure was necessary after an extraction of an infected tooth. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that you only have preventive dental included with your benefits and this procedure was not a preventive service. 
 
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 pay for the reline of the complete maxillary denture provided on November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) services.
You asked the Plan to pre-approve the PET scan. You say that there is no other modality, other than a PET scan, that can accurately help to assess the disease status in the enrollee. You say that the enrollee's case is unique and the requested PET scan is necessary to monitor his course of malignancy. The Plan denied your request. The Plan says the clinical information provided shows that the requested study would exceed the allowed limit. The Plan says that further imaging with PET/CT is not supported and the request is not indicated at this time.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has refractory Hodgkin's disease and started Opdivo in February of 2020. Our physician reviewer found that the enrollee has had 3 subsequent PET scans and that computed tomography (CT) services can be used to follow the 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) services.
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).
You asked the Plan to pre-approve the A-C IOL. You say that the Plan's coverage of the requested service would eliminate your having to ask for new prescriptions every two years. You say that this would save the insurance company money in the long run. The Plan denied your request. The Plan says Astigmatism or presbyopia correcting functionality of an IOL implanted following cataract surgery is not covered by Medicare.
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 you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve an Astigmatism-Correcting Intraocular Lens (A-C IOL).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 2, 2020.
You asked the Plan to pay for lab tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim and does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is billed as the Place of Service (POS). 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 plan's decision to deny payment because the Place of Service (POS) code 81 was billed on this claim is not supported, because the claim form submitted shows the Place of Service (POS) code 11 was billed on this claim. However, the documentation submitted did not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information,
we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that your dentures were damaged because the provider did not handle it with care. You also say that due to the fault of the previous dentist, you would like to see if your current dentist can repair or replace them. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago.
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, dentures are limited to one set every 5 years. Replacement of lost, stolen, or broken dentures less than 5 years of age does not meet criteria for pre-authorization of a new denture. The record shows that you received a maxillary partial denture on April 4, 2017 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 10, 2019 to September 11, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the enrollee needs help paying for these services.The Plan denied your request. The Plan says there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from September 10, 2019 to September 11, 2019.