Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pre-approve3-dimensional radiotherapy plan, including dose-volume histograms identified with CPT 77295.You asked the Plan to pre-approve3-dimensional radiotherapy plan, including dose-volume histograms. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item orservice 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 3-dimensional radiotherapy plan, including dose-volume histograms. Our reviewer says that the documentation supports that the requested services are medically reasonable or necessary. Our physician reviewer found the physician did provide a letter describing the need for 3D planning and provided the rationale that the patient has a large BMI such that 4-field plan and review of a dose volume histogram would be needed to assure no unacceptable not spots. Generally, 3D radiation is necessary when the 2D radiation plan results in unacceptable normal tissue dose exposure and toxicity risks (uncommon with palliative treatment). It usually implies the need to spare normal tissues in a manner that cannot be achieved with 2D radiation. The rationale provided in the case file is plausible and appears to be an exceptional situation for which the need of 3D RT can be justified. The documentation supports that the need for 3D radiation has been substantiated in this case and that it would be within accepted standards of care to use 3D as opposed to 2D radiation.Our reviewer also said that the Local Coverage Determination (LCD), L34151 used by the plan is for SRS/SBRT which would not apply in this case. Therefore, we did not use LCD L34151 to substantiate our decision.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3-dimensional radiotherapy plan, including dose-volume histograms have been met.Therefore, we decided that the Plan has to pre-approve3-dimensional radiotherapy plan, including dose-volume histograms identified with CPT 77295.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 thereis 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 inpatient psychiatric services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the documentation supports that the requested inpatient psychiatric services are medically reasonable and necessary. Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on June 22, 2020 with Unspecified Mood Disorder. Based upon review the records provided it was expected the enrollee would improve in a reasonable period of time as the enrollee did have dangerousness to self and others but no auditory or visual hallucinations, delusions and was not showing any behavioral issues or withdrawal symptoms. It did appear that active treatment was taking place. It did appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. It did appear that the records were supervised and evaluated by a physician. The enrollee met criteria for the requested acute inpatient mental health treatment as the enrollee was shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory, visual hallucinations or delusions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from June 9, 2019 to June 13, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that that the patient did not meet medical necessity for inpatient level of care at the second midnight and was stable for discharge but remained hospitalized due to social issues.
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 the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from June 9, 2019 to June 13, 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.
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 are appealing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require the intensity of services provided in an IRF. Specifically, the enrollee is not shown to be able to perform 15 hours per week of rehabilitative services. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says you do not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. Medicare guidelines say that in order for a CGM to be covered, all of
the above criteria must be met. The enrollee must have been using a BGM and performing frequent (four or
more times a day) testing. Medicare also says therapeutic CGMs are covered when the enrollee is insulintreated
with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous
insulin infusion (CSII) pump. In this case, the file shows that you do not perform four or more blood glucose
testing per day and that you are not insulin treated with multiple (three or more) daily injections. Based on this
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous spaces.
You asked the Plan to pre-approve the spacer. You say that you would like reconsideration because this is the most appropriate, medically necessary treatment. The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of member's condition.
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 spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spaces is experimental and more research is needed to show its safety and efficacy. 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 spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous spaces.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bimatoprost.
You asked the Plan to pre-approve Bimatoprost. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Bimatoprost is not covered under your Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Bimatoprost.
Benefits for Bimatoprost may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 the enrollee by an out-of-network provider on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eye Drops.
You asked the Plan to pre-approve the eye drops. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says drug coverage for the member is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eye Drops.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve white glass with gold cap for bridge tooth 31 and 28, and the false tooth for bridge tooth 29 and 30.
You asked the Plan to pre-approve white glass with gold cap for bridge tooth 31 and 28, and the false tooth for bridge tooth 29 and 30. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested dental services are not a covered benefit.
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 requested items or services are not among those covered under this benefit. The requested services are only covered when you are missing only one upper front tooth or only two lower front teeth. Review of the file shows that you are missing other teeth than the ones required for this service. Therefore, we decided that the Plan does not have to pre-approve white glass with gold cap for bridge tooth 31 and 28, and the false tooth for bridge tooth 29 and 30.
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 are appealing based on medical necessity. The
Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
enrollee does require skilled physical therapy and occupational therapy, the enrollee does not require treatment
in an intensive rehabilitation therapy program. There is concern that the enrollee would not be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility. Care at the skilled nursing facility level would be more appropriate.
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-approvehomehealth nursing services. You asked the Plan to pre-approvethe home health services. You say that you would like reconsideration because your provider recommended home health services.The Plan denied your request. The Plan says no home health order has been obtained.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that the records do not show that skilled nursing services are required to effectively provide treatment, care or services in order to improve your condition, or to establish a maintenance program to maintain your condition and/or prevent deterioration. Our physician reviewer found enrollee had previously been receiving home health services but these services ceased as of March 31, 2020 and no new order for subsequent services has been received by the Plan. 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 home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health nursing services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a complex cystometrogram provided on November
22, 2019.
You asked the Plan to waive the copayment for a complex cystometrogram. You say that you did not receive a
complex cystometrogram on this date and disagree with the charges. The Plan denied your request. The Plan
says that the claims were processed correctly and you are being charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide medical records showing whether services occurred.
Therefore, we decided that the Plan has to waive the copayment for a complex cystometrogram provided on
November 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.
Appeal type: Home Health
Decision: Partially Favorable

You asked the Plan to pre-approve home health care. You say that you really need these skilled nursing visits.
The Plan says that the denial of authorization for additional home health skilled nursing is correct.
We decided that the Plan has to pre-approve 4 additional home health care visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health care. Our reviewer says
that you meet the Medicare criteria for 4 additional home health skilled nursing visits. Our physician reviewer
found based on review of the available records, you would benefit from 4 additional visits by home health
skilled nursing for dressing your wound and teaching your spouse and yourself to provide wound 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 4 additional home health care visits have been met. Therefore, we decided that
the Plan has to pre-approve 4 additional home health care visits.
We also decided that the Plan does not have to pre-approve the remainder of the requested home health
care.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health care. Our reviewer says
that you do not meet the Medicare criteria for home health care beyond the visits already approved. Our
physician reviewer found that you are medically stable with no evidence of need for nursing care. There is no
initial visit or follow-up by the home care provider for wound care if provided. Once your spouse and you are
taught to care for your wound, skilled nursing services will not be required to effectively provide treatment,
care, and/or services which are medically necessary for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does
not have to pre-approve .
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.