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

We decided that the Plan does not have to pay for the skilled nursing services provided from September 28, 2019 to October 6, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have skilled nursing or skilled rehabilitation needs nor did they receive skilled therapy only available at a skilled nursing facility.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse.
The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 28, 2019 to October 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the service is not medically necessary. The Plan also says that the periapical x-ray of tooth #15 does not show evidence that the tooth is 50% or more involved by decay, fracture, or missing a cusp(s).
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found due to the fact that the documentation does not indicate significant coronal breakdown of tooth #15, the criteria for coverage for a crown restoration (D2740) for tooth #15 has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided December 15 to December 18, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $350 per day copayment for days 1-5 for inpatient care. You have been asked to pay a $700 copayment for two days of inpatient hospital care. 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 inpatient hospital care provided December 15 to December 18, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing provided on March 29, 2019.
You asked the Plan to pay for the definitive drug testing. You say that this testing was ordered and provided based on the direction of the treating provider. The Plan denied your request. The Plan says that there is no valid order provided as the form is not signed.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider. In this case, the lab requisition form is noted to be electronically signed by the provider. The lab report appears to show that the testing was provided as ordered. The denial based on no valid order is not supported. Therefore, we decided that the Plan has to pay for the definitive drug testing provided on March 29, 2019.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve hypoglossal nerve stimulation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this procedure is considered investigational, and not reasonable or necessary by Medicare.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary and meet coverage requirements. 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in applying the clinical information provided for review to the requirements of the applicable LCD. The enrollee has none of the listed contraindications. The enrollee is older than 22 years, and has a BMI less than 35 mg/m (BMI of 28.35). The enrollee had a polysomnography (PSG) is performed within 24 months of first consultation for HGNS implant on May 20, 2019. The enrollee has has predominantly obstructive events (defined as central and mixed apneas less than 25% of the total AHI); and a has an AHI of 60. The enrollee was seen by a sleep medicine fellow in the ENT clinic who documented intolerance to CPAP. There is an absence of complete concentric collapse at the soft palate level, as seen on a drug-induced endoscopy procedure. There are no other anatomical findings that would compromise performance of device (e.g., tonsil size 3 or 4 per standardized tonsillar hypertrophy grading scale). It should be noted that the enrollee has a history of UPPP. In as much as it appears that the enrollee has met all of the specific requirements for this request. 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 services have been met. Therefore, we decided that the Plan has to pre-approve hypoglossal nerve stimulation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that there is no indication for an MRI of the lumbar spine. There are complaints of radiculopathy, but no bowel or bladder incontinence, and there are no abnormal neurologic findings on physical exam. In addition, there was no documentation of a failure to improve after a recent (within three months) six-week trial of physician-guided clinical care with clinical re-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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that 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 was admitted to the
hospital on April 8, 2020 for bilateral lower extremity pain. He has received multiple surgeries to treat lower
extremity necrosis, vascular occlusion and pressure sores. The enrollee is receiving ongoing wound care. 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. LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on November
4, 2019.
You asked the Plan to pay for the dental service. You say that you assumed that the denture would be covered
by your insurance. You also say that the office staff was pushy. The Plan denied your request. The Plan says
the maxillary partial denture is not medically necessary.
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. The Plan covers the dental
service when the services are medically necessary and reasonable.
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 the dental service. Our reviewer says that the
partial denture is not medically necessary. Our physician reviewer found the documentation provided shows
that you were advised that the partial denture had a poor long term prognosis. The reviewer found that given
the poor prognosis of the remaining teeth, the requested procedure would not be considered medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does
not have to pay for a maxillary partial denture (D5213) provided on November 4, 2019.
Your complaint about the office staff being pushy is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 25, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
codes are not among the only tests listed as provider-performed procedures.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
The file shows that procedure codes 81003, 85025, 84443, 80053, and 80061 were provided to the enrollee.
The services are not specified as provider-performed microscopy procedures and waived tests. 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 pay for the lab services provided on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ingrezza.
You asked the Plan to pre-approve Ingrezza. You say that the drug is indicated for the enrollee's medical
condition. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient
prescription drugs.
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 Ingrezza.
Benefits for Ingrezza 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep testing.
You asked the Plan to pre-approve sleep testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered for the indications listed in LCD L33405. 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 sleep testing. Our reviewer says that the requested sleep testing is not medically reasonable and necessary. Our physician reviewer found that the diagnosis of OSA was confirmed in the past with an AHI of 74.3 on a prior sleep test. A repeat diagnostic PSG test may be useful in certain cases. For example, if the member had more than a 10% change in weight, surgical intervention for the treatment of OSA (i.e., tonsillectomy, adenoidectomy, uvulopalatoplasty, maxillomandibular advancement surgery), or an evaluation of a fabricated oral mandibular advancement appliance (OAT). However, the records do not show that these cases apply to the member. The review has determined that the requested sleep testing is not medically reasonable or necessary according to the coverage indications established in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sleep testing have not been met. Therefore, we decided that the Plan does not have to pre-approve sleep testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 3, 2019 to
November 1, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not require any additional skilled services that could not have been provided in an alternate setting other
than a SNF.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from October 3, 2019 to November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve follow-up care with an out-of-network neurosurgeon.
You asked the Plan to pre-approve the follow-up care with an out-of-network neurosurgeon. You say that you were treated by the requested out-of-network provider in the hospital for a recent fracture to T12 and L1. You say that you then had a follow-up video visit and completed an x-ray with this out-of-network provider. You say that you are wearing a brace at this time and need follow-up with the provider you have been seeing, in order to determine whether there is a need for surgery and for management of your treatment. You say that the in-network neurosurgeon you were assigned is not available due to his work in the Covid-19 respiratory clinic. The Plan denied your request. The Plan says the enrollee is required to receive care from providers who are part of your primary care physician's specialty network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 follow-up care with an out-of-network neurosurgeon. Our reviewer says that follow-up care with an out-of-network neurosurgeon is not medically necessary. Our physician reviewer found there is nothing unique about the enrollee's condition that would make it medically necessary to continue care out-of-network. The plan has shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of 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 the follow-up care with an out-of-network neurosurgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve follow-up care with an out-of-network neurosurgeon.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on June 12, 2019.
You asked the Plan to pay for lab tests. You say that the ordering physician's medical record is kept by the
physician's office, and you are only provided necessary information to complete the ordered lab tests. The Plan
denied your request. The Plan says that the denial of payment for these services is correct, because the ordering
provider did not submit progress notes needed in order to determine the clinical utility of this testing.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering practitioner is in-network or out-of-network with the Plan. The Plan did not
submit documentation of prior notice that this testing would not be covered. Without this information, we
cannot determine whether the lab order made constituted plan-directed care, which
would justify coverage of these tests. Therefore, the Plan has not shown that its denial of payment for these
services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for
laboratory testing provided on June 12, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not medically necessary.
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 scan. Our reviewer says that the
requested scan is medically reasonable and necessary. Our physician reviewer found at issue is a repeat CT
scan of the chest, as a follow-up to a previous CT on 9/6/2019, which showed multiple pulmonary nodules as
well as other abnormalities. The largest nodules were 1.3 cm. The patient is high risk for lung cancer based on
smoking history. The follow-up chest CT is considered reasonable and 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 scan have been met. Therefore, we decided that the Plan has to pre-approve
CT scan of the chest for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Respimat inhalation spray.
You asked the Plan to pre-approve Stiolto Respimat. 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 Part D prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stiolto Respimat inhalation spray.