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

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a skilled nursing facility will not provide adequate care for the enrollee's current health condition.The Plan denied your request. The Plan says the enrollee does not have a complex illness requiring acute care for more than 25 days.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH)for decubitus ulcers in the setting of spina bifida. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available.As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Superion interspinous spacer procedure for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysa 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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show 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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Superion interspinous spacer procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary. You say that the enrollee is at high risk due to mobility and walking issues.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.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. The patient was admitted for surgery to treat afemur fracture. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 27, 2020,by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 forthe medical services provided on August 27, 2020,by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 20, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on August 20, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveknee arthroscopy (29881, G0289).You asked the Plan to pre-approveknee arthroscopy. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.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 or service 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 knee arthroscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found criteria for knee arthroscopy is met. The magnetic resonance imaging (MRI) shows a complex meniscal tear. The enrollee has tried and failed multiple conservative measures over the past 6 months for knee pain. Yes, there is degenerative joint disease (DJD) present, but that does not completely exclude the need for a knee scope procedure in this case with a complex meniscal tear.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroscopy have been met.Therefore, we decided that the Plan has to pre-approveknee arthroscopy (29881, G0289).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-approve a heavy-duty hospital bed (E0303).
You asked the Plan to pre-approve the heavy-duty hospital bed. You say that the records provided support the need for the requested hospital bed. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that heavy-duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 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 heavy-duty hospital bed. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation shows that the enrollee weighs 225.99 pounds. The enrollee does not weigh more than 350 pounds. There are no extenuating circumstances supported by medical documentation that make the requested type of hospital bed 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 heavy-duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed (E0303).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and diagnostic radiology and the copayment for an outpatient surgeryprovided by a participating provideron August 10, 2020.You asked the Plan to waive the coinsurance for an injection and diagnostic radiology and the copayment for an outpatient surgery. You say that you do not understand why one time it was covered and the second time it was not.The Plan denied your request. The Plan says the correct cost sharing amounts have 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). Your contract with the Plan clearly says that you must pay a 20% coinsurancefor Medicare Part B prescription drugs/in-network, a 10% coinsurance for outpatient diagnostic tests/in-network/x-rays and radiology, and a $300 copayment for outpatient surgery/in-network. You have been asked to pay a 20% coinsuranceof the allowed amount for an injection, a10% coinsuranceof the allowed amount for diagnostic radiology service, and a $300 copayment for an outpatient surgery.An injectionfalls within the Medicare Part B prescription drugs/in-network benefit category, diagnostic radiology servicesfalls within the outpatient diagnostic tests/in-network/x-rays and radiology benefit category,and an outpatient surgery falls within the outpatient surgery/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This costsharing 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 coinsurance for an injection and diagnostic radiology and the copayment for an outpatient surgeryprovided by a participating provider on August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine transportation services.You asked the Plan to pre-approvethe routine transportation services. You say that you have an appointment set up to see a urologist and have no other transportation options. You say that you need an extension on the mileage allowance so that you can go to this appointment.The Plan denied your request. The Plan says the requested transportation is to a location that is farther than the routine transportation benefit allows.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The records show that the location you are requesting routine transportation to is approximately 70 miles from your home address. This exceeds the 50-mile limitation that is part of your routine transportation benefit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveroutine transportation services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee replacement (27447).
You asked the Plan to pre-approve total knee replacement. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that total knee replacement surgery is medically necessary when certain criteria is met. 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 total knee replacement. Our reviewer says that the services are not medically necessary. Our physician reviewer found criteria for knee replacement is not met. There is no documentation of a recent trial and failure of physical therapy (PT) for knee pain. More conservative measures are needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total knee replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee replacement (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment foremergency physician service provided on May 29, 2020.You asked the Plan to make additional payment foremergency physician service. You say that you were told that you would only have one copayment of $90, so the Plan and provider should work together to dissolve this extra billing matter.The Plandenied your request. The Plan says the denial of payment is correct, because the Plan has paid the Medicare allowable amount for this claim and cannot make additional payment.The Plan must follow Medicare rules. Medicare rules say that for an out-of-network, Medicare participating provider, neither the Plan nor the enrollee pay balance billing. The Plan contract says that, as a member of the Plan, the Plan does not allow providers to charge balance billing to the enrollee.

We looked at the file and Medicare rules. The Plan has paid the Medicare allowable amount for this claim. Therefore, you are not responsible for the balance billing amount that the provider is charging you. However, the Plan is also not responsible for this balance billing amount. The Plan has stated that if you choose to use an out-of-network provider you are responsible for the difference between the allowed amount and the billed charges, but based on the Medicare rules and your contract with the Plan you are not responsible for this amount and the Plan protects you from balance billing even if they pay less than the full billed charges for a claim. The Plan should make efforts to protect you from this balance billing.Therefore, we decided that the Plan does not have to make additional payment foremergency physician service provided on May 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.

You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 a CT scan of the chest. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the requested CT Scan is 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 a CT scan of the chest have not been met.Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest
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. The Plan denied your
request. The Plan says the services can safely be received in other settings, for example: a skilled nursing
facility, home with home health services or home with outpatient therapy.

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.

The enrollee was admitted for surgery to treat a fractured patella. Medical conditions are stable. There are no
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveinsertion of a new or replacement of permanent pacemaker (33208).You asked the Plan to pre-approveinsertion of a new or replacement of permanent pacemaker. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.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 or service 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 insertion of a new or replacement of permanent pacemaker. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based on AHA/ACC Pacing indications criteria guidelines in the absence of another certain cause of syncope or drug effects, prophylactic dual chamber pacing is indicated in patients with documented syncope and bifascicular block (Class II indication). In the absence of specific cardiac pathology criteria from CMS, this would therefore meet the CMS criteria for medical necessity and accepted medical practice based on current published guidelines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a new or replacement of permanent pacemaker have been met.Therefore, we decided that the Plan has to pre-approveinsertion of a new or replacement of permanent pacemaker (33208).If the Plan does not agree with our decision,theycan 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 openthe case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Foreseehome monitoring system.You asked the Plan to pre-approvethe Foreseehome monitoring system. You say that the requested device is FDA-cleared and is a daily home-based monitoring system for patients at risk of vision loss due to age-related macular degeneration. You say that the requested device is medically necessary because the enrollee is at risk of vision loss.The Plan denied your request. The Plan says medical studies have not proven that the device being requested is helpful for treatment of the enrollee's dry stage macular degeneration.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 Foreseehome monitoring system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found home monitoring of the enrollee's macular degeneration with Foreseehome is not medically necessary in this case.  The enrollee has bilateral intermediate dry macular degeneration.  The standard of care in this situation is home self-monitoring with Amsler grid, and regular follow-up examinations.  The Foreseehome monitoring system has been evaluated and validated by prospective analysis and has been shown to be a safe and effective system for exudative macular degeneration surveillance for high-risk individuals in relatively limitedstudy.  It is not the standard of care for treatment or monitoring for the enrollee's diagnosis.  The Foreseehome system may be more effective than Amsler grid, but only a single study of relatively short duration exists to compare the efficacy. There is no evidence that the Foreseehome system improves disease outcomes, or that it would be superior for treatment of the enrollee's intermediate non-exudative macular degeneration as compared with standard treatments.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Foreseehome monitoring system have not been met.Therefore, we decided that the Plan does not have to pre-approvea Foreseehome monitoring system