Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has MRI findings including stenosis of varying severity, many that are "moderate." FDA contraindications include scoliosis and obesity, and which have not been adequately addressed in the medical records. Detailed documentation is not evident regarding scoliosis with no documentation of the Cobb angle. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, the Superion interspinous spacer (Vertiflex device) is not medically reasonable or necessary, for treatment of this enrollee's medical condition.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for vision services provided by a participating provider on June 15, 2020.
You asked the Plan to waive the copayment for vision services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says that the correct copayment has been applied.
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. A 2020 H7115 Evidence of Coverage was not provided. We find that without that information we are unable to uphold. Therefore, we decided that the Plan has to waive the copayment for vision services provided by a participating provider on June 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

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 the notes do not show a need for skilled nursing care or skilled therapy care in a skilled therapy facility.

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 daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued 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 not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior cervical fusion surgery.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no clear pseudoarthrosis noted on imaging.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee presents with ongoing, chronic neck pain with left sided weakness and numbness. He notes the neck pain has increased significantly in the last couple of weeks in the midline of the back of the neck. There is some tingling in the right foot. Exam reveals no sensation in the left upper and lower extremities. Sensation is significantly decreased in the face. There is antalgic gait secondary to chronic left leg weakness. Strength is 3+ to 4/5 in the left upper and lower extremities. Imaging studies confirm previous posterior decompression from C2-3 through C6-C7 levels along with anterior fusion hardware at C3-C4 and C6-C7. However, the MRI and CT do not demonstrate pseudarthrosis. CT notes intact C3-C7 anterior and posterior decompression/fixation construct without residual/recurrent spinal canal stenosis in the fixed segment, solid bony fusion C4-C6. There is no instability noted. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior cervical fusion surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient level of care.

You asked the Plan to pre-approve inpatient level of care. You say that the requested inpatient level of care is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care is not medically necessary.

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 inpatient level of care. Our reviewer says that the requested inpatient level of care is not medically necessary. Our physician reviewer found the enrollee presented to the emergency department. She was confused, required medication adjustments, and required restraints due to aggressiveness. ECG with bradycardia. Vitals stabilized prior to admission. Based on the enrollee stabilizing and only requiring short-term monitoring for her combativeness, there are no other significant acute care needs to warrant inpatient services. Observation status would have been appropriate for basic monitoring and care until stable for discharge to 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 inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient level of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 19, 2019.
You asked the Plan to pay for the dental service. You say that your provider only recently told you that he was in network. You say that you did not know this before. You say that you had been told by the dental office that they did not accept your plan. You also say that the time limit should be waived for this submission. The Plan denied your request. The Plan says claims need to be submitted within one year of the date of service. The Plan also says that your claim was not received until October 1, 2020, more than 1 year after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the dental service was not filed until October 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan and coinsurance for contrast material provided by a participating provider.

You asked the Plan to waive the copayment for a CT scan and coinsurance for contrast material. You say that you do not agree with this. You say that this is way too high. The Plan denied your request. The Plan says the correct copayment and coinsurance has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital and a 20% coinsurance for outpatient diagnostic tests/medical supplies.

The enrollee has been asked to pay a $250 copayment for a CT scan and a 20% coinsurance of the allowed amount for contrast material. The total allowed amount is $1,327. The total amount you are being asked to pay for the contrast material is $265.40 ($1,327 x 20% = $265.40). The total amount you are being asked to pay is $515.40 ($250 + $265.40 = $515.40). The total amount you are being asked to pay is a CT scan and contrast material falls within the outpatient diagnostic tests/advanced imaging services/outpatient hospital and outpatient diagnostic tests/medical supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan and coinsurance for contrast material provided by a participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond February 4, 2021.
You asked the Plan to pre-approve continued SNF care. You say that the enrollee needs additional care due to his frailty. The Plan denied your request. The Plan says the enrollee's needs are custodial.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the records provided, the enrollee does not have any identifiable skilled nursing service needs. While the enrollee has skilled therapy needs, he does not require therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond February 4, 2021.
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 service is medically necessary. The Plan denied your request. The Plan says services could be obtained 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 there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation 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 IRF care have not been met. Specifically, the enrollee does not have a need for intensive rehabilitation services. This means the enrollee's medical needs can be obtained in a lower level of care and admission to an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on September 24, 2020.
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed code is not supported.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on September 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services.

You asked the Plan to pre-approve the continuation of SNF services. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of continued admission in skilled nursing facility does not meet the requirements for approval.

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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of the admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. The enrollee did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis at a SNF level of care The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, her function had plateaued and she did not require any further inpatient skilled rehab services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. The member required custodial services. The denial for further inpatient skilled care is upheld.

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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve methadone tablets 10mg 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 the medication falls under Part D coverage.
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 methadone tablets 10mg for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT), head or brain (70470).

You asked the Plan to pre-approve the head CT scan. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the medical records submitted do not document a reason for imaging of the brain.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the head CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a head CT is not considered part of routine surveillance for an oropharyngeal cancer. This enrollee has no signs or symptoms to suggest brain involvement. He has had no evidence of disease upon completion of radiation. A head CT 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 the head CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), head or brain (70470).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital admission for a total knee arthroplasty.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is to undergo a procedure that is not on the inpatient only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities which are expected to necessitate a prolonged stay. 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital admission for a total knee arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra drops 5% for the enrollee.
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says this is a benefit exclusion.
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 Xiidra drops 5% for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until October 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on June 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LINX Reflux Management System (43284).
You asked the Plan to pre-approve LINX Reflux Management System. You say that the service is medically necessary. The Plan denied your request. The Plan says neither Medicare nor your Medicare Advantage health plan covers this request. Medical studies haven't proven that the device(s) is helpful for treatment of your health problem. The requested hospital stay isn't covered because it's associated with a procedure that isn't covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LINX Reflux Management System have not been met. Specifically, the service requested is not a covered service. Therefore, we decided that the Plan does not have to pre-approve LINX Reflux Management System (43284).