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

We decided that the Plandoes not haveto pre-approvepercutaneous image-guided lumbar decompression for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medicaly necessary.The Plandenied your request. The Plansayscoverage of clinical trials is covered by Original Medicare, but not allowed by the plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with a history of low back and lower extremity pain, with signs/symptoms reported consistent with neurogenic claudication. Clinical exam findings are consistent with imaging evidence of severe L3/4 and L4/5 multifactorial spinal canal stenosis, and severe left L4/5 neuroforaminal narrowing due to broad-based disc extrusions, facet joint hypertrophy, and ligamentum flavum thickening. At L5/S1, there was a broad-based disc extrusion extending superiorly along the posterior L5 body, with moderate facet joint hypertrophy and ligamentum flavum thickening, and month to moderate left and moderate to severe right neuroforaminal narrowing due to exercise, posterolateral osteophytes, and right facet joint hypertrophy. She has reportedly failed long-term conservative treatment. Under consideration is a request for percutaneous image-guided lumbar decompression (MILD procedure). There is current evidence based medical literature support for the use of this procedure for the treatment of spinal stenosis. This enrollee presents with severe central canal stenosis at L3/4 and L4/5 and severe left L4/5 neuroforaminal narrowing with disc extrusions at the L3/4, L4/5 and L5/S1 levels. However, there is no clear discussion to support the medical necessity of minimally invasive surgery (overstandard lumbar decompression) in the setting of severe spinal canal/neuroforaminal stenosis along with disc extrusions (which typically cannot be fully addressed as an aggregate with the described minimally invasive surgery.) Therefore, this request for percutaneous image-guided lumbar decompression would not be considered medically reasonable and necessary at this 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 the surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvepercutaneous image-guided lumbar decompression for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on September 23, 2019, and October 16, 2019.
You asked the Plan to pay for the services. You say that you didn't know this was an out-of-network provider. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on September 23, 2019, and October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 7, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on October 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent in nature. The Plan also says the services could be provided 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit provided on October 16, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvean intensive outpatient program.You asked the Planto pre-approvethe program. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered by Medicare.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 program. Our reviewer says that the requested program is not considered medically reasonable and necessary in this case. Our physician reviewer found you do not require intensive outpatient treatment as being medically necessary or reasonable. You could be treated in a lesser restrictive environment as you are not showing the required intensity to meet the 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 the program have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean intensive outpatient program
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transit kit option from provider. You asked the Plan to pre-approve a wheelchair transit kit option (K0108). You say that the enrollee needs the wheelchair and accessories.The Plan denied your request. The Plan says the primary function of a transit kit is for use outside the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a transit kit option from provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to payforthe complete series of intraoral x-rays provided on October 17, 2019.You asked the Plan to pay forthe complete series of intraoral x-rays. You say that you requested that your previous dentist send x-rays to your new dentist but those were partial. You also say that you do not know how your new dentist would know what line of action to take regarding your dental health without these x-rays.The Plan denied your request. The Plan says the service is 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 coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan only coversbitewing x-rays. Intraoral x-rays are not a covered benefit.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays provided on October 17, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 13, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 fromout-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 thePlan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the cervical spine (72125) provided on October 14, 2019. You asked the Plan to waive the copayment forthe CT scan. You say that the copayment should be waived.The Plan denied your request.The Plan says the correct copayment was applied.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 $225 copayment for Advanced Imaging. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the Advanced Imaging 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 forComputed Tomography (CT) of the cervical spine (72125) provided on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the colorectal screening provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory testing. You say that you are a participating provider with the Plan for the date of service at issue. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services can be provided in network. The Plan also says that the services were not urgent or emergent.
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 referring provider is not a network provider either. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the colorectal screening provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on October 21, 2019.
You asked the Plan to pay for the panoramic x-ray. You say that you had to seek care elsewhere. You say that
this wouldn't be an issue if your provider still accepted your insurance. The Plan denied your request. The Plan
says the panoramic x-ray is only allowed once every three years.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit
of one panoramic x-ray every three years. The records show that you received a panoramic x-ray on May 15,
2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the
panoramic x-ray provided on October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered to on April
25, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary, as the enrollee struggles with mobility, and has experienced six falls in the past month. The Plan denied your request. The Plan says therapy can continue to be provided in a less intense setting.
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Veltassa medication (J8499).You asked the Plan to pre-approvethis medication.You say that this medication is medically necessary for the treatment of the patient's condition.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Veltassa medication (J8499).Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for recurrent bacteremia and new discitis. The enrollee is receiving a prolonged course of antibiotics and his usual hemodialysis. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital care provided July 4, 2019 to July 9, 2019.You asked the Plan to pay forthe inpatient hospital care. You say that you are requesting reconsideration for payment.The Plan denied your request. The Plan says this service was billed incorrectly.The Plan must follow Medicarerules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the plan says that the claim was not billed correctly. A corrected claim needs to be submitted. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital care provided July 4, 2019 to July 9, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approvePT services to be provided by an out-of-network facility.You asked the Plan to pre-approvePT services. You say that it would be hard for you to drive over 45 minutes or 2 hours away to receive care.The Plan denied your request. The Plan says that you must receive your care from a network provider.Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. We were able to confirm that the Plan does not have contract providers located within reasonable distance and travel time from your home who can provide the PT services you require. None of the network providers offered are within 30 miles or 45 minutes of your residence which is within the plan's service area. Under Medicare rules, this means that contract providers are not accessible to you.Therefore, we decided that the Plan has to pre-approvePT services to be provided by  an out-of-network facility.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that the insurance has covered the items before the last past years and you need them urgently.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 18, 2019 through
July 22, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record does show that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or
observation care) would span two midnights. Inpatient admission was 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from July 18, 2019 through July 22, 2019.
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.