Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT).
You asked the Plan to pre-approve the SBRT. You say that SBRT is the best and most viable treatment option for the enrollee's bone metastases. The Plan denied your request. The Plan says that the type of treatment being requested is not considered medically necessary for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SBRT. Our reviewer says that SBRT is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee received pelvic radiation for prostate cancer in 2014 and now has an oligometastatic recurrence in the right ischium. Our physician reviewer found that stereotactic body radiation therapy (SBRT) utilizes precisely targeted radiation to a tumor while minimizing radiation to adjacent normal tissue, allowing treatment of small or moderate-sized tumors in either a single or a limited number of dose fractions. Our physician reviewer found that SBRT is utilized mostly for patients who have a reasonable (more than 6 months) life expectancy, persistent or recurrent bone pain after a standard course of EBRT, and require reirradiation. Our physician reviewer found that this is in keeping with evidence-based guidelines on palliative radiation therapy (RT) for bone metastases from ASTRO. Our physician reviewer found that the enrollee fits this criteria and the service 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 the SBRT have been met. Therefore, we decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the records provided support the need for myocardial perfusion imaging services. The Plan denied your request. The Plan says there is no indication that the enrollee is unable to participate in a treadmill stress test as opposed to myocardial perfusion imaging.
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 myocardial perfusion imaging. Our reviewer says that myocardial perfusion imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found the records show the enrollee has recurrent nonexertional syncope, no chest discomfort, a normal cardiac exam, normal ventricular function and no electrocardiographic abnormalities. Our physician reviewer found that the likelihood of an ischemic trigger is very low, such that additional testing for coronary ischemia is debatably medically necessary. Moreover, our physician reviewer found that if stress testing were thought to be medically necessary then treadmill electrocardiography should be sufficient in this enrollee with a normal (interpretable) electrocardiogram. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on March 29, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device. You say that the requested device is medically necessary due to the enrollee's worsening heart failure. You say that the CardioMEMS device will allow for better monitoring and managing of the enrollee's symptoms, which lead to repeat heart failure hospitalizations. The Plan denied your request. The Plan says the requested device is no medically reasonable and necessary. The plan says that there is a lack of clinical data indicating the effectiveness of this device.
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 CardioMEMS device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Our physician reviewer found that concerns have been raised about potential bias in this trial calling into question the results. Our physician reviewer found that, because of this, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and is not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that the device should still be considered experimental or investigational. 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS 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 the requested services to avoid ending up in the hospital again. 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. 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. Our physician reviewer found based on available records, you do not meet criteria for coverage of IRF. You are currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While you may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee from April 29,
2019 to June 20, 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 the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of
the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
services provided to the enrollee from April 29, 2019 to June 20, 2019.
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 care is medically necessary for this enrollee. The Plan denied your request. The Plan says the enrollee is medically stable and does not require an intensive, multidisciplinary rehab program
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. Our physician reviewer found the enrollee is a female with iron deficiency anemia, leg edema, and recurrent falls. She currently is requiring maximal assistance for ADLs. The member is physically debilitated. Edema is managed with bandaging; she has some low sodium levels due to diuresis. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician management of her rehab program. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly maximal assist for personal care and ADL's and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide (G0156).
You asked the Plan to pre-approve a home health aide. You say that you need help in your home. 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. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 a home health aide. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical information does not support that you are homebound. You are being seen on an outpatient basis and have a normal gait. When seen there was no documented use of an assistive device at the visit. There is no identified skilled nursing or physical therapy need. When Home Health Aide services are requested and are not in support of a skilled need, the service is not considered 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 a home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide (G0156).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 5, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that you had fallen at the YMCA and feel that since the YMCA called the ambulance and the accident occurred on their premises, their insurance should be responsible for the $250. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these services. 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 ambulance services provided on July 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services coded as D0150, D1110, D0220, D2392 provided from January 23, 2019 to February 11, 2019.
You asked the Plan to pay for the dental services. You say that you had a cavity under a crown which had to be removed for the work to be done and then replaced. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
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. The health plan contract specifically says the plan does not cover services performed by an out of network dentist. 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 dental services coded as D0150, D1110, D0220, D2392 provided from January 23, 2019 to February 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF care.. You say that a continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not require skilled care.
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 the continuation of SNF care.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to acute care with an altered mental status related to urosepsis and aspiration pneumonia. Our physician reviewer found that the enrollee was treated with IV antibiotics and IV fluids. Our physician reviewer found that the enrollee was discharged to SNF on January 13, 2020. Our physician reviewer found that the enrollee's prior level of function was being wheelchair bound and cared for by his son at home and having a caregiver for 6 hours for three days per week. Our physician reviewer found that the enrollee's level of function as of January 13, 2020 was being at maximal assist with bed mobility and transfers, ambulating 3-4 steps with minimal to moderate assist, maximal assist with feeding and grooming, dependent with toileting, maximal assist with upper body dressing, and dependent with lower body dressing. Our physician reviewer found that the enrollee's therapies have been significantly impacted by his dementia and inability to participate.
Our physician reviewer found that the records do not support that the enrollee needs continued daily speech therapy, physical therapy, and occupational therapy. Our physician reviewer found that there are no noted daily skilled complex nursing needs. Our physician reviewer found that, while the enrollee may benefit from continuing speech therapy, physical therapy, and occupational therapy, the records do not support the need for continued daily therapy. 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 continuation of SNF care. have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L3 Kyphoplasty.
You asked the Plan to pre-approve L3 Kyphoplasty. You say that you are in pain and are struggling to do basic things. The Plan denied your request. The Plan says this 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 L3 Kyphoplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that it remains unclear if the L3 compression fracture is the true cause of the enrollee's back pain. Kyphoplasty has been shown to not be effective in the treatment of compression fractures. It is not more effective than conservative 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 L3 Kyphoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve L3 Kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve private nurse services for 84 hours per week for 12 months.
You asked the Plan to pre-approve the additional services. The Plan denied your request. The Plan says the additional hours are not covered
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 additional services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is receiving private duty nursing care for 35 hours per week as covered by Medicare. Private duty nursing care beyond this level is not covered. 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve private nurse services for 84 hours per week for 12 months.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.
You asked the Plan to pre-approve the physician's services. You say that you are established with this specialist and you were advised that you need a corneal transplant and the doctor specializes in this kind of treatment. The Plan denied your request. The Plan says the care you need is not an emergency and it is not needed urgently. The Plan has eye specialists available in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic polysomnography (PSG) services (CPT 95810).
You asked the Plan to pre-approve the diagnostic PSG services. You say that the previous sleep study shows that the enrollee needs a PAP titration sleep study. The Plan denied your request. The Plan says the enrollee had a prior split night sleep study billed with CPT code 95811 on date of service November 26, 2019. The plan says that the testing in dispute is a duplicate of the diagnostic portion of the prior performed split night study. The plan says that the records provided do not support the need for any PAP titrations. The plan says that the sleep study in dispute 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 diagnostic PSG services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a previous spit-night study on November 26, 2019 confirmed complex sleep apnea and PAP titration was unsuccessful, including BiPAP, with emergence of central respiratory events. Our physician reviewer found that the enrollee has complex sleep apnea, and a previous titration with CPAP and BiPAP was unsuccessful, in part because of the worsening of central apneas during PAP. Our physician reviewer found that the enrollee needs a PAP titration study of VPAP with ASV, not a repeat diagnostic PSG, which is considered not 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 the diagnostic PSG services have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic polysomnography (PSG) services (CPT 95810).