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

We decided that the Plan does not have to pre-approve vertebral augmentation of L3.

You asked the Plan to pre-approve the surgery. You say that the procedure is to correct a fracture. The Plan
denied your request. The Plan says medical necessity is not established.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found both vertebral augmentation with cement and spine jack procedure are relatively contra-indicated in the
presence of retropulsion of the vertebral body fragments. Therefore, the request is deemed not medically
reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve vertebral augmentation of L3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla.

You asked the Plan to pre-approve Otezla. You say that Otezla is an appropriate option for the enrollee. The Plan denied your request. The Plan says Otezla is not covered under the Part B benefit.

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 Otezla.

Benefits for Otezla 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that that you are functioning at a home care level and capable of
rehabilitation with repetitive exercise and intermittent therapy oversight and review.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
SNF services are medically reasonable and necessary. You have stabilized medically. Although you do not
have any skilled nursing needs, you have had a significant decline in physical functioning. You do require
skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline
or complications. Our physician reviewer found that your condition meets Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have been met. The Plan must continue coverage for the SNF
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled
nursing facility (SNF) services.
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: Favorable

We decided that the Plan has to waive the copayment for CT scan provided on December 9, 2020.

You asked the Plan to waive the copayment for the CT scan. You say that you have other insurance, and you should not owe a copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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 contract says enrollees should expect to pay a $75 - $300 copayment depending on the Medicare-covered diagnostic radiology services (not including x-rays) for CT scans, MRIs, myelography, PET scans, MRA, SPECT, CTA, nuclear cardiology, and stress tests). The Plan does not clearly state which copayment applies to CT scans.

We looked at your contract with the Plan. We did not see where the contract states you must pay a $300 copayment for the CT scan. The contract states there will be a copayment between $75 and $300 but does not clarify when you should be expected to pay each amount. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the CT scan provided on December 9, 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 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 the enrollee needs continued therapy. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.

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. Our physician reviewer found the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee will be limited by weight bearing restrictions. The enrollee's care needs can be met at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 22, 2020.
You asked the Plan to pay for the prophylaxis. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. The Plan also says that you were informed on February 2, 2021 that periodontal maintenance (D4910) is covered 3 times a year for people with gum disease, and no calls prior to this were located.
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, prophylaxis (D1110) is limited to two procedures per plan year. The record shows that you received a prophylaxis (D1110) on January 16, 2020, and July 16, 2020 and your prophylaxis (D1110) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 22, 2020.
Your complaint about possibly being misinformed by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are participating providers available.

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 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 a referral to an out-of-network provider.
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. You say that you need LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron 4mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no pharmacy benefit with the plan.
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 Ondansetron 4mg tablet for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in a different setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. These services are not needed on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abdominal aortic aneurysm screening (76706).

You asked the Plan to pre-approve an abdominal aortic aneurysm screening. You say that this is medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that that payment may be made for a one-time ultrasound screening for Abdominal Aortic Aneurysm (AAA) for a beneficiary who has a family history of abdominal aortic aneurysm, is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime, or is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determination process.

We looked at the file and Medicare rules. The records do not show that you have a family history or AAA. At this time you are 76 years old and do not manifest other risk factors. Based on this information, we decided that Medicare rules for coverage of an abdominal aortic aneurysm screening have not been met. Therefore, we decided that the Plan does not have to pre-approve an abdominal aortic aneurysm screening (76706).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate anesthesia care.

You asked the Plan to pre-approve moderate anesthesia care. You say that this service is medically necessary. The Plan denied your request. The Plan says based on the clinical criteria established, this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that except for rare and unique circumstances, moderate anesthesia care is not 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 moderate anesthesia care. Our reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer found that the enrollee is a 70-year-old male with a history of chronic low back pain and chronic pain syndrome. His provider has recommended a thermal facet joint radio frequency ablation procedure to be done with Monitored Anesthesia Care (MAC). The review indicates that there is no specific statement in the records concerning medical necessity for intravenous sedation/MAC for this minimally invasive procedure. This is not a rare or unique circumstance where the medical necessity of sedation is unequivocal and clearly documented in the medical record. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of moderate anesthesia care have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate anesthesia care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says there is no expectation that additional improvement is attainable in a reasonable period of time.

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 additional visits. Our physician reviewer found that you have had at least 17 sessions of outpatient physical therapy. You have low back pain with radiation into the lower extremities. You have made slow progress in your trunk range of motion and lower extremity strength during your therapy program. An abnormal gait pattern continues to be noted. You are participating in a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. The requested services are not required 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services (CPT code: 20660) provided on January 22, 2021.

You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure. The Plan states the other codes that were billed have been forwarded to the Health Plan's Provider Resolution department as the denials in dispute did not meet the criteria for review by the Health Plan.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 20660. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services (CPT code: 20660) provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep brain stimulation.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a covered diagnosis.

The Plan must follow Medicare rules. The rules say that deep brain stimulation is covered for Parkinson's disease or an essential tremor.

The appeal request shows a diagnosis of G24.9 - dystonia. Medicare does not cover deep brain stimulation for this diagnosis. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve deep brain stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 23, 2020.

You asked the Plan to pay for the office visit. You say that you are not sure what the denial was for. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 office visit provided by an out-of-network provider on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be safely received in another 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 admission to a long term acute care hospital (LTACH) for the enrollee.