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

We decided that the Plan does not haveto pre-approve percutaneous decompression of the spine.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is not in a clinical study.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 surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of grade 3-10/10 low back and left thigh pain radiating to the knee. Significant limitations are noted in weight bearing tolerance and activities of daily living. Clinical exam findings did not evidence a focal neurologic deficit. There are imaging findings of L3-S1 mild to marked central canal and neuroforaminal narrowing with nerve root impingement at all levels. There was a 7 mm anterolisthesis reported at L4/5. She has reportedly failed long-term conservative treatment, including epidural steroid injection and neuroplasties. Under considerationis a request for percutaneous image-guided lumbar decompression (MILD procedure), apparently planned at the L3/4 and L4/5 levels. There is current evidence based medical literature support for the use of this procedure for the treatment of spinal stenosis. This enrollee presents with moderate to marked central canal stenosis and neuroforaminal narrowing at L3/4 and L4/5 and mild central canal and marked neuroforaminal narrowing at L5/S1, with nerve root impingement at the L3/4, L4/5 and L5/S1 levels. Thereis no clear discussion to support the medical necessity of minimally invasive surgery over standard lumbar decompression. In the setting of marked central canal and neuroforaminal stenosis as well as nerve root impingement, such findings would typically not be fully addressed with minimally invasive surgery. Therefore, this request for percutaneous image-guided lumbar decompression would not be considered medically reasonable and necessary at this time.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 Plandoes not haveto pre-approvepercutaneous decompression of the spine.
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-approveIRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee currently lives in an assisted living facility and is receiving home health care. She is only able to walk with small steps and modifiedassist, with kyphosis and bilateral foot drop. She fatigues quickly with any ambulation. She is noted to need maximal to modified assist with toileting, toilet transfers, and lower body dressing. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. She may benefit from further therapy but does not appear to be able to tolerate an intensive therapy program 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.You asked the Plan to pre-approve inpatient mental health treatment. 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 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 mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment facility beyond the date in question of February 14, 2020 forward. They could have been treated in a lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, and delusions. They were not showing any anxiety or racing of thought and were being cooperative and compliant.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 mental health treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation services from August 30, 2019 through September 5, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for acute inpatient rehabilitation services. You say that you believe the claim should be covered in full as your skilled nursing facility benefit. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 medical records and confirmed the services rendered were inpatient rehabilitation and those services apply to your inpatient hospital care benefit. Review of the file shows that you were admitted on August 30, 2019 and discharged on September 5, 2019. You were asked to pay a $350 copayment per day from August 30, 2019 through September 3, 2019, days 1-5 of your inpatient stay. There were no copayment charges from September 4, 2019, day 6 of your inpatient hospital care until your day of discharge September 5, 2019. Per your contract there is a $350 copayment per day required for days 1-5. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day. 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 acute inpatient rehabilitation services from August 30, 2019 through September 5, 2019 provided by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye exam (92014), and photography of the retina with interpretation and report (92250) provided on August 13, 2019.You asked the Plan to waive the copayment foran eye exam, and photography of the retina. You say that you didn't think you had a copayment. The handbook says you had a $0 copay for screening for eye disease as part of the eye exam. It does not say unless they find something unusual and you think that's misleading.The Plan denied your request. The Plan says vision care with outpatient physician services hasa $30 copayment.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 $30 copayment for outpatient physician services. You have been asked to pay a $30 copayment for an eye exam, and photography of the retina. These servicesfall within vision care with outpatient physician services benefit category. Your contractshows there isa $30 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk. The photography of the retina falls under code 92250. This means that you havebeen 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 foran eyeexam (92014), and photography of the retina with interpretation and report (92250) provided on August 13, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee is currentlyundergoing treatment at an acute care hospital (ACH) for cardiac and renal problems. The enrollee was apparently intubated/ventilated twice, but is not currently intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that  The Plan denied your request. The Plan says that your request exceeds the benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from April 23, 2019 through May 13, 2019, July 8, 2019 through July 15, 2019, July 20, 2019 through August 1, 2019, December 2, 2019 through December 23, 2019 and January 3, 2010 through February 12, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 physician reviewer found that the enrollee's current level of function is ambulating independently in the room, transferring withno assistive device independently, independent with bed mobility, independent with balance, and supervision with all activities of daily living (ADLs). There are no noted daily skilled complex nursing needs. He is ambulating household distances and requires no assistance with ADLs, mobility and transfers. While he may benefit from continuing speech, physical, and occupational therapy, the records do not support the need for daily therapy.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-approveskilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on October 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.The provider submitted a claim for procedure code 71045 under claim number 820192911075038. The Plan previously paid this code for the date of service at issue under claim number 820192911074756.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered to on October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on August 30, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plandenied your request. The Plan says the services are not covered.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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charges for the out-of-network services you received from September 16, 2019, to September 19, 2019.
You asked the Plan to waive the deductible charges. The Plan denied your request. The Plan says you must meet your deductible for out-of-network services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,500 deductible for out-of-network services. The services you asked the Plan to pay for were provided by an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the services was received on September 16, 2019 to September 19, 2019. This means that you have been asked to pay the correct amount based on your plan contract. Therefore, we decided that the Plan does not have to waive the deductible charges for the out-of-network services you received from September 16, 2019, to September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care, and does not require transfer.
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 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. In this case, ongoing care needs include respiratory support with intermittent BiPAP and oxygen supplementation, surveillance laboratory studies, close fluid balance management, hemodialysis, and therapy services. 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forComputed Tomography (CT) of the head or brain (70450) provided September 21, 2019. You asked the Plan to waive the copayment forthe CT scan. You say that the CT scan did not provide useful results and you should have been sent for an MRI instead.The Plan denied your request. The Plan says the service was rendered and the correct copayment 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 $325 copayment for Diagnostic Radiology. You have been asked to pay a $136.44 copayment for the CT scan. The CT scan falls within the Diagnostic Radiology benefit category. The allowable amount of $136.44 is less than the $325 copayment stipulated in the contract. 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 forComputed Tomography (CT) of the head or brain (70450) provided September 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea DexcomG6 continuous glucose monitor (CGM) -receiver and sensors.You asked the Plan to pre-approvea Dexcom G6 CGM -receiver and sensors. You say that the items 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 therapeutic CGMs and related supplies are covered when specific 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 a Dexcom G6 CGM -receiver and sensors. Our reviewer says that the items are not medically necessary. Our physician reviewer found a therapeutic continuous glucose monitor is not medically necessary at this time. Specifically, the records provided indicate that you are not performing frequent blood sugar checks that determine adjustment to insulin dosing.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 Dexcom G6 CGM -receiver and sensors have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom G6 continuous glucose monitor (CGM) -receiver and sensors.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 18, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 medical services provided on June 18, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.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 shortness of breath apparently related to interstitial lung disease and cumulative trauma disorder. The enrollee is not intubated/ventilated. 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.