Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.You asked the Plan to pre-approve the requested therapy. The Plan denied your request. The Plan says there is no clear evidence to support proton therapy over IMRT for treatment efficacy or long-term toxicity.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 requested therapy. Our physician reviewer found that there is no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long term toxicity. Proton beam therapy for primary treatment of prostate cancer should only be performed in the context of a prospective clinical trial or registry. The submitted documents do not indicate the requested treatment is part of such a clinical trial. Therefore, the requested proton therapy is not medically reasonable and necessary above the plan-preferred IMRT.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 requested therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee can be safely cared for at a lower level of care.
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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are not well enough to return home at this time. The Plan denied your request. The Plan says you do not need intensive rehab, physician supervision, or a multidisciplinary team for 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 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 physician reviewer found that you are at a minimal assist level for bed mobility and transfers. You do not require the intensity of services provided at an IRF. Specifically, You are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 Accu-Chek test strips. You asked the Plan to pre-approve the requested supplies. You say that you already have an Accu-Chek device, and just need the test strips. The Plan denied your request. The Plan says you do not have a condition that requires a specific meter. The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred, or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Nutri-pharmaceutical specialized blend injections and treatment (97032, 97016, 96372, J3490, J3420, J3415, J3411) provided November 25, 2019. You asked the Plan to pay for Nutri-pharmaceutical specialized blend injections and treatment. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not indicate that these services are necessary for treatment of the 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 pay for Nutri-pharmaceutical specialized blend injections and treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the provided services were medically necessary to diagnose, treat or otherwise manage the enrollee's 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 Nutri-pharmaceutical specialized blend injections and treatment have not been met. Therefore, we decided that the Plan does not have to pay for Nutri-pharmaceutical specialized blend injections and treatment (97032, 97016, 96372, J3490, J3420, J3415, J3411) provided November 25, 2019.
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 you are not currently receiving the physical therapy you need.The Plan denied your request. The Plan saysyour needs can be met 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 above.We asked our physician reviewer to carefully reviewthe 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from physical and occupational therapy, but the documentation does not support that your functional status requires an 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 inpatientrehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination of the knee (73564) provided January 14, 2020.
You asked the Plan to pay for a radiologic examination of the knee. You say that this service was medically necessary. The Plan denied your request. The Plan says the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 a radiologic examination of the knee. Our reviewer says that the billed code is not supported in this case. Our physician reviewer found the medical records provided do not include an interpretation report for radiologic examination, knee; complete, 4 or more views for date of service January 14, 2020, therefore this service cannot be verified. 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 radiologic examination of the knee have not been met. Therefore, we decided that the Plan does not have to pay for a radiologic examination of the knee (73564) provided January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for alcohol detoxification.
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says you do not have acute withdrawal symptoms.
The Plan must follow Medicare rules. Medicare rules say that when the high probability or occurrence of medical complications during detoxification necessitates the constant availability of physicians and/or complex medical equipment found only in the hospital setting, inpatient hospital care is considered reasonable and necessary. We looked at the file and Medicare rules. In this case, there is insufficient medical documentation that show you require detoxification in a hospital setting. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for alcohol detoxification.
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 the records provided support the need for IRF care.The Plan denied your request. The Plan says the records do not show that the enrollee requires services from a rehab doctor three times per week or services of a specialized rehab team. The Plan says that the services needed can be received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status and low activity tolerance requires an 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets.
You asked the Plan to pre-approve Eliquis. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Eliquis tablets.
Benefits for Eliquis 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: 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 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. While the enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation does not support that the enrollee's functional status requires or can tolerate an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental core buildup with dental code D2950.
You asked the Plan to pre-approve dental core buildup. You say that you have a broken crown that is cutting your tongue. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is not covered by the Plan.
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. Therefore, we decided that the Plan does not have to pre-approve dental core buildup with dental code D2950.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97116, 97110 and 97530) provided from January 23, 2020 to January 31, 2020.You asked the Plan to pay for therapy services. You say that these services are payable with Modifier 59.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, we have confirmed that code 97110 has a bundled relationship with code 92526and cannot be paid as billed. Code 97530 is mutually exclusive to code 97116. The record does not show that codes were billed with a modifier to indicate a separate and distinct procedure. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97116, 97110 and 97530) provided from January 23, 2020 to January 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional physical therapy services.You asked the Plan to pre-approveadditional services. You say that the enrollee needs to continue physical therapy to get stronger.The Plan denied your request. The Plan says the enrollee has met long-term goals, and is at baseline for functional mobility.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.The documentation shows that 8 physical therapy visits were requested. The Plan has agreed to pre-approve 6 visits. 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 2 additional visits. Our physician reviewer found that the enrollee demonstrates a decline in functional mobility. For weakness and debility, physical therapy is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP). In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function. There is no indication that residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD) (0275T).You asked the Plan to pre-approve percutaneous image-guided lumbar decompression (PILD) (0275T). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee is not enrolled in a research study.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. We looked at the file and Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression or commercially known as the mild procedure will be covered when provided in an approved clinical study. The file does not show that the enrollee is enrolled in an approved clinical study.Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD) (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or
heat exchanger (99190) provided on February 10, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this is a mandatory service. The Plan denied your request. The Plan says payment for this service
is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on February 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on March 18, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you sought care at urgent care but they were closed. You say that you should pay the $5 urgent care copayment instead. The Plan denied your request. The Plan says the copayment applied correctly.
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 $50 copayment for each emergency room visit. You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on January 29, 2020 from an out-of-network
provider.
You asked the Plan to pay for hearing aids. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you are appealing for reconsideration of the denied
charges.
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.
Review of the file show that you purchased hearing aids on January 29, 2020 from an out-of-network provider.
Your EOC states, you must see an in-network supplemental hearing aid provider to use this benefit. The
requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for hearing aids purchased on January 29, 2020 from
an out-of-network provider.