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

We decided that the Plan has to pre-approve surgical removal of bone joints between wrists and fingers.

You asked the Plan to pre-approve hand surgery. You say that the enrollee qualifies for this surgery. The Plan denied your request. The Plan says that the denial of authorization for this procedure is correct, because this surgery is not medically necessary.

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 hand surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the notes document a positive carpometacarpal (CMC) joint grind test and X-Ray documents CMC arthritis. The enrollee has had multiple injections and has been treated in the office multiple times for this problem. CMC joint tendon arthroplasty is appropriate and should be approved as the enrollee has failed conservative measures over 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 hand surgery have been met. Therefore, we decided that the Plan has to pre-approve surgical removal of bone joints between wrists and fingers. 

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on September 3, 2020.
You asked the Plan to waive the copayment for the ultrasounds. You say that you were paying a $15 copayment for similar tests in the past and were not informed of a new copayment requirement. You say that you are on a fixed income and cannot afford this copayment. The Plan denied your request. The Plan says the copayments applied correctly.
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 $155 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a total of $281.42 for the ultrasounds.
Service
Allowed Amount
Standard Copayment
Member Liability
Abdomen Ultrasound
$144.26
$155
$144.26
Head and Neck Ultrasound
$137.16
$155
$137.16
TOTAL:
$281.42
The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 the ultrasounds provided on September 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on August 30,
2020.
You asked the Plan to pay for the paramedic intercept services. You say that this service was medically
necessary for your fathers life. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the
paramedic intercept services provided on August 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 31, 2020, outpatient surgery services provided from March 23, 2020, through April 2, 2020 and outpatient surgery services provided from November 16, 2020, through November 19, 2020.
You asked the Plan to waive the copayment for the CT scan and outpatient surgery services. You say that you were billed almost a year later for the services rendered. You say that you are on a fixed income and don't agree with the patient responsibility. The Plan denied your request. The Plan says the copayments applied correctly.
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 $200 copayment per provider, per date of service for complex radiology and a $350 copayment per date of service for outpatient surgery in an outpatient hospital facility. You have been asked to pay a total of $900 for the CT scan and outpatient surgery services.
Date of Service
Service
Standard Copayment
Member Liability
January 31, 2020
CT Scan
$200
$200
March 23, 2020-
April 2, 2020
Outpatient Surgery Services
$350
$350
November 16, 2020-November 19, 2020
Outpatient Surgery Services
$350
$350
TOTAL:
$900
The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The outpatient surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the CT scan provided on January 31, 2020, outpatient surgery services provided from March 23, 2020, through April 2, 2020 and outpatient surgery services provided from November 16, 2020, through November 19, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits.
You asked the Plan to waive the copayment for the office visits. You say that you saw the nurse instead of the doctor for your visit, therefore you think the copayment should be waived. The Plan denied your request. The Plan says the correct cost share applied to the claims based on the services billed.
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 $40 copayment for physician/practitioner services. You have been asked to pay less than or equal to $40 copayment for each of the office visits. The office visits fall within the physician/practitioner services 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 the office visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lower partial denture with a flexible base (D5226) provided on September 12, 2020.You asked the Plan to pay forthe dental item. You say that you are aware that the dental item is not covered. You say that the enrollee was advised that the dental office could appeal the denial for the partial and submit for an alternate benefit. You say that benefits for the alternate treatment of a fixed prosthetic should be considered. You also say that the enrollee is aware of the replacement clause limitation that will be applied.The Plan denied your request. The Plan says lower partial denture with a flexible base is not listed as a covered service. The Plan also says that any services not listed are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coveragerules 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 forthe lower partial denture with a flexible base (D5226) provided on September 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.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 based on the medical records provided the complexity of your nursing, medicaland rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clearyou would be able to fully benefit and/or participate in an IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that 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 were admitted for a total hip replacement. Your medical problems are stable. You do not have complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Additionally, 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 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for atrial fibrillation with rapid ventricular response, congestive heart failure, and acute kidney failure. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal epidural steroid injection (64483).
You asked the Plan to pre-approve transforaminal epidural steroid injection. You say that you are ordering a repeat injection because you are trying to get the enrollee more than 50% overall benefit by doing a second injection at the documented source of his problem. The Plan denied your request. The Plan says given the documentation provided, the enrollee does not meet the guidelines for the requested spinal injection and does not appear 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 transforaminal epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has achieved 50% pain relief but the request for a repeat injection is before 3 months has elapsed. Therefore, the request does not meet the LCD criteria and the request is deemed not medically reasonable or 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 transforaminal epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural steroid injection (64483).
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical alert system.

You asked the Plan to pre-approve a medical alert system. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as these are emergency communications systems and do not serve a diagnostic or therapeutic purpose.

Although this device may be appropriate, it is not covered by Medicare Therefore, we decided that the Plan does not have to pre-approve a medical alert system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee continues to require daily physician assessments with close monitoring and will require another 25 days of recovery.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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. Our physician reviewer found the short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the current acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as inpatient rehabilitation facility, skilled nursing facility, or sub-acute rehabilitation.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you require additional trips to get to your dialysis treatment.The Plan denied your request. The Plan says that your request exceeds thelimit set.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of forty-eight (48) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCT scan of blood vessels in the chest for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no active pulmonary symptoms.The Plan must follow Medicare rules. Medicare rules say that CT 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found themost recent documentation from December 2020 indicates no pulmonary issues and improved chest x-ray.   an urgent CT scan of the chest was ordered to evaluate for pulmonary embolism.  There are no notes available from that visit. There is no documentation to support the need for a chest CT scan to evaluate for pulmonary embolism. The requested service cannot be recommended.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCT scan of blood vessels in the chest for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levalbuterol Neb 1.25 mg for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The rules also say that in order to be eligible for coverage under Medicare Part B the charge for a drug must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician. Although this self-administered drug could be covered as a supply for the nebulizer (DME), Medicare does not separately cover this DME in a nursing home. Therefore, the drug will be dispensed by a pharmacy and sent to the SNF for use in the DME. The cost of this drug will not be included in the SNF's bill, meaning that it is not eligible for coverage under Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Levalbuterol Neb 1.25 mg for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.