Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve12 visits for removal of devitalized tissue (97597), debridement; first 20 sq. cm or less (11042), and debridement; each additional 20 sq. cm (11045) to be provided from December 23, 2019 to March 31,2020.You asked the Plan to pre-approve12 visits for removal of devitalized tissue, debridement; first 20 sq. cm or less, and debridement; each additional 20 sq. cm. You say that services were provided for one visit prior to requesting authorization due to medical necessity. Due to the holiday, there was a delay in requesting prior authorization.The Plan denied your request. The Plan says that the services were rendered prior to requestingprior authorization. Therefore, coverage criteria has not been met.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 12 visits for removal of devitalized tissue, debridement; first 20 sq. cm or less, and debridement; each additional 20 sq. cm. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the necessity for the procedures are well documented. The procedures aremedically necessary and indicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 visits for removal of devitalized tissue, debridement; first 20 sq. cm or less, and debridement; each additional 20 sq. cm have been met.Therefore, we decided that the Plan has to pre-approve12 visits for removal of devitalized tissue (97597), debridement; first 20 sq. cm or less (11042), and debridement; each additional 20 sq. cm (11045) to be provided from December 23, 2019 to March 31, 2020. 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 toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network
provider.
You asked the Plan to pre-approve office visits. You say that this provider works in the same office and is
willing to treat the enrollee. The Plan denied your request. The Plan says the denial of authorization for these
services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an
in-network plastic surgery specialist.
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. 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
the medical services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heavy duty rollator walker (E0147).
You asked the Plan to pre-approve the walker. You say that your current walker does not work properly and has caused you to fall three times. You do not feel safe with the current walker. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria.
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 walker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee is unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. Therefore, the requested DME is not shown to be medically necessary or 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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve heavy duty rollator walker (E0147).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you did not call for the ambulance and refused treatment when the ambulance arrived. You say that you are unable to pay for the ambulance services in question.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 August 19, 2019. 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 forthe ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (CPT 81327).
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this test is not likely to impact a patient's treatment plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The requested test is billed with a code that Medicare does not consider to be medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (CPT 81327).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 29, 2019.
You asked the Plan to pay for the services. You say that the services were not hospice related. The Plan denied your request. The Plan says the enrollee was enrollee in hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services provided on March 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis for the enrollee.
You asked the Plan to pre-approve Lucentis. The Plan denied your request. The Plan says that you did not inform the member of the cost savings associated with Avastin.
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 Lucentis. Our reviewer says that Lucentis is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Avastin or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found the enrollee's condition does not meet criteria for coverage of Lucentis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of the CPAP device provided by "the provider". You asked the Plan to pre-approvecontinued use of the CPAP device. You say that you need the CPAPdevice. The Plan denied your request. The Plan says your doctor did not provide documentation that you use this device on a regular basis.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 no documentation of a clinical reevaluation that you are benefiting from PAP therapy.Based on this information, we decided that Medicare rules for coverage of continued use of the CPAP device have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of the CPAP device provided by "the provider".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge services (CPT 99239) provided on August 1, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99239 is "Hospital discharge day management; more than 30 minutes".We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not show that more than 30 minutes of hospital discharge day management services were provided on August 1, 2019. 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 forthe discharge services (CPT 99239) provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive inherited cancer panel provided to the enrollee on July 18, 2019.
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. The Plan says experimental or investigational services 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 pay for the panel. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found the documentation does not support that the comprehensive inherited cancer panel was medically reasonable and necessary for the enrollee in this case. There is no documentation that the enrollee in this case has symptoms or a medical condition necessitating testing. The tests at issue in this case were screening in nature. There is no documentation to support the medically necessity of the comprehensive inherited cancer panel for the enrollee in this case. 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 panel have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive inherited cancer panel provided to the enrollee on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tension based scoliosis orthosis for the enrollee. You asked the Plan to pre-approve a Tension based scoliosis orthosis. You say that this orthosis is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 Tension based scoliosis orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the documentation provided, the severity of the enrollee's scoliosis is unclear. Bracing to correct or prevent the worsening of degenerative scoliosis is not generally indicated. A tension brace is not indicated to treat sacroiliitis, osteoarthritis of the hips, tendonitis of the hip or hip bursitis. The documentation does not support that the requested DME is currently medically necessary or 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 Tension based scoliosis orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea Tension based scoliosis orthosis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed Zoledronic Acid.
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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary. Our physician reviewer found the patient tried and failed Zoledronic Acid. The documentation does not support that Zoledronic Acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on June 5, 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 Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
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 pay for the services. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 molecular genetic hereditary predictive screening testing provided to the enrollee on June 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee. You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says current treatment can be provided in the current setting.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory syncytial virus (RSV) and pneumonia. Initially treated with antibiotics, oxygen and BiPAP, the enrollee was eventually intubated/ventilated. The enrollee subsequently received a tracheotomy. The enrollee is currently tolerating several hours a day on pressure support settings. It has not yet been established that she has failed ventilator weaning or is in need of LTACH services. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules 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 for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvean MRI of theabdomen (74183).You asked the Plan to pre-approvean MRI of the abdomen (74183). You say that the requested MRI of the abdomen is medically necessary.The Plan denied your request. The Plan says that the requested MRI of the abdomen 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 of the abdomen (74183). Our reviewer says that the requested MRI of the abdomen is medically necessary. Our physician reviewer found the enrollee is a 70 year old woman with abdominal pain, weight loss, elevated liver enzymes, and an abnormal alphafetoprotein (AFP) level. Her evaluation has included abdominal X-ray, CT scan of the abdomen and pelvis, upper endoscopy (demonstrating esophagitis and a Schatzki ring), colonoscopy (demonstrating moderate diverticulosis and a sessile polyp), as well as laboratory testing. The CT scan with contrast of the abdomen and pelvis on 12/13/19 demonstrated mild mural thickening of the wall of the large bowel, most notable distally. There were no definite acute abnormalities of the liver, gall bladder or bile ducts identified. The available documentation supports that an MRI of the abdomen is medically reasonable and necessary for the enrollee in this case. The enrollee has unexplained abdominal pain and weight loss, with elevated LFTs, and an elevated AFP which can be a marker for tumors of the GI tract, particularly hepatocellular carcinoma. Her evaluation thus far has not been diagnostic. While the enrollee's CT scan did not reveal definite acute abnormalities of the liver, gall bladder or bile ducts, the sensitivity of a CT in this setting is estimated to be in the neighborhood of 68%. AnMRI has significantly greater sensitivity.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 of the abdomen (74183) have been met.Therefore, we decided that the Plan has to pre-approvean MRI of the abdomen (74183).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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the complexity of the member's nursing, medical management and rehabilitation needs requires an inpatient stay and an interdisciplinary team approach to the delivery of her rehabilitation care. The member requires physical therapy for mobility, occupational therapy for remaining activities of daily living and adaptive equipment. A speech therapy evaluation is indicated for identifying any residual dysphagia, dysarthria, cognition, and communication impairments. The member has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet her rehabilitation needs. 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that LTACH is the safest and most efficient care level based on his medical needs.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.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 askedour 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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for necrotizing pancreatitis requiring multiple abdominal surgeries. The enrollee was intubated/ventilated peri-operatively, but is no longer intubated/ventilated. The enrollee received temporary hemodialysis, but is no longer receiving hemodialysis. The enrollee continues to receive wound care, supplemental nutrition and rehabilitative services. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 for the enrollee.