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

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. You say that that the member has impaired strength and balance and is at risk for falls and decreased participation in functional tasks without ongoing therapeutic intervention. The Plan denied your request. The Plan says additional PT visits are not reasonable and necessary under Medicare guidelines.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 an additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has had time to be instructed and transition to a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.
You asked the Plan to pre-approve an additional twelve (12) PT visits. The Plan denied your request. The Plan says the documentation does not show that the unique skills of a physical therapist are needed to improve, maintain, or prevent deterioration of the member's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 an additional twelve (12) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records you appear to have improved with therapy to the point of having minimal decrease in range of motion, minimal increase in strength recently and no recent improvement in pain level. Further skilled therapy at this point does not appear to be likely to achieve any significant further improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.
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 additional twelve (12) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle test strips.

You asked the Plan to pre-approve Freestyle test strips. You say that these are medically necessary. The Plan denied your request. The Plan says that there is no clinical information to show medical necessity for the non-preferred brand of test strips.

The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers.

The items at issue are Freestyle test strips. Freestyle is not a preferred provider with the Plan for diabetic supplies. Accu-Chek and OneTouch are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Freestyle test strips.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show the enrollee does not need an intensive program with a team of health care professionals and doctors that specialize in rehab.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensive outpatient program (IOP) treatment.
You asked the Plan to pre-approve the intensive outpatient program (IOP) to be provided by the out-of-network provider. You say that the in-network provider did not address your needs with regards to your substance abuse despite communicating that you were not satisfied and uncomfortable with their mental health as opposed to substance use disorder and that their IOP program is limited by offering treatment via zoom and is scheduled no more than 3 times a week. You say the requested provider has been able to provide services in person and can provide the services up to 5 times a week based on your needs. The Plan denied your request. The Plan says that the Plan does not cover out-of-network services rendered with the exceptions of emergency care or urgently needed services that you get from an out-of-network provider, medical care that Medicare requires our Plan to cover and providers in our network cannot provide this care with authorization before seeking care, and dialysis services when you are temporarily outside the service area, or when prior 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 an intensive outpatient program (IOP) to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a non-therapeutic continuous glucose monitor (HCPCS A9276, A2977, A9278).
You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. The Plan says the "A codes" that were requested are never covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes. The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pay for a non-therapeutic continuous glucose monitor (HCPCS A9276, A2977, A9278).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Retacrit.

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 Retacrit. Our reviewer says that the enrollee does not meet criteria for the requested Retacrit. Our physician reviewer found Retacrit is indicated for the treatment of myelodysplastic syndrome when the hemoglobin prior to initiating therapy is less than 10. This enrollee has a hemoglobin in the 12 range and Retacrit would not be indicated. The service is not reasonable or 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tomosynthesis with screening mammography (77063).
You asked the Plan to pre-approve the 3D mammogram. You say that places are not doing a 2D mammograms anymore and are only offering 3D mammograms. The plan is not approving the 3D mammogram. If you have to have a 2D mammogram first, please provide a list of providers that offer it still. The Plan denied your request. The Plan says the documentation submitted does not support that the enrollee meets the criteria for the requested serviced.
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 3D mammogram. 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 clinical rationale for the requested study. The documentation indicates that the enrollee's last mammogram was 3 years ago. There is no provided documentation of breast abnormality in history or physical exam requiring a full diagnostic study. No current evidence that shows digital tomosynthesis along with screening mammography is beneficial in women with average breast cancer risk. The review has determined that the requested item is not 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 3D mammogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a Tomosynthesis with screening mammography (77063).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert System (E1399).
You asked the Plan to pre-approve this item. You say that a Life Alert System is medically necessary. The Plan denied your request. The Plan says the requested device does not meet Medicare criteria for coverage.
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, as it does not directly treat a medical condition. Therefore, we decided that the Plan does not have to pre-approve a
Life Alert System (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 had network providers available who could have provided 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 drug testing provided on December 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (E0766).
You asked the Plan to pre-approve tumor treatment field therapy. You say that this service is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested service have not been satisfied.
The Plan follows Medicare rules. Medicare rules say that the tumor treatment field therapy is subject to the criteria listed 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 tumor treatment field therapy. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found in this case, the record indicates that the initial resection was in 2018, followed by adjuvant therapy. The record indicates that the enrollee had progression and underwent further resection and further adjuvant therapy. In 2021 the enrollee had further progression. The enrollee has had progression. The elements of the coverage determination are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tumor treatment field therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (E0766).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided June 11, 2018 to June 16, 2018.
You asked the Plan to pay for the inpatient hospital care. You say that DRG 871 was correctly billed for this inpatient stay. The Plan denied your request. The Plan says that the records support DRG 193 instead.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital care. Our reviewer says that DRG 871 is appropriately billed. Our physician reviewer found the enrollee was admitted with a fever of greater than 101.5 (reported to be 104 at home), tachycardia, a pulmonary infiltrate, a creatinine of 2 (above baseline 1.3-1.5), a lactate of 1.6, and a procalcitonin level of 2.9. The following day the enrollee developed toxic encephalopathy. The enrollee satisfies the definition of severe sepsis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital care provided June 11, 2018 to June 16, 2018.
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 for the custodial care services received from December 28,
2020, to January 23, 2021.
You asked the Plan to pay for the custodial care services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the custodial care services have not been met. Specifically, we find that the services at issue in this
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the
custodial care services received from December 28, 2020, to January 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight (8) PT visits.

You asked the Plan to pre-approve an additional eight (8) PT visits. The Plan denied your request. The Plan says additional PT visits are not reasonable or necessary as the enrollee has not made significant progress and does not appear to have a potential to improve.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 an additional eight (8) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 additional eight (8) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight (8) PT visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient physical therapy (PT) visits
provided August 20, 2020 to October 27, 2020.
You asked the Plan to waive the copayment for the outpatient PT services. You say that you are being billed
$669.30 on top of the $25 copayment you've paid for your visits. You were told you had to pay $25 per visit
and you're 100% covered. The Plan denied your request. The Plan says the claims were processed correctly per
the Evidence of Coverage.
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 $300
copayment for each outpatient hospital facility visit.
You have been asked to pay $1,274 for the outpatient PT visits. The outpatient PT visits falls within the
Outpatient rehabilitation 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 outpatient physical therapy (PT) visits provided August 20, 2020 to October 27, 2020.