Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Leuprolide acetate (J9217).
You asked the Plan to pre-approve Leuprolide acetate. You say that this is medically necessary. The Plan denied your request. The Plan says that this drug is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Leuprolide acetate. Our reviewer says that the requirements for coverage of Leuprolide acetate have been met. Our physician reviewer found the requested drug is FDA-approved and is listed in the NCCN Clinical Practice Guidelines in Oncology (NCCN) with the specific ICD-10 diagnosis (that is being treated) for the drug. It is medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Leuprolide acetate have been met. Therefore, we decided that the Plan has to pre-approve Leuprolide acetate (J9217).
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 8,
2020, by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be
reprocessed for payment. The Plan denied your request. The Plan says the service was rendered by a nonparticipating
provider.
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 had network providers
available who could have provided 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 subsequent nursing facility care provided on
July 8, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the foot (73630) provided on January 20, 2021.

You asked the Plan to waive the copayment for an x-ray of the foot. You say that you received an x-ray as follow up care to your surgery. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $35 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $35 copayment for an x-ray of the foot. The EOC confirms that $35 is the required copayment for this service. An x-ray of the foot falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure. 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 an x-ray of the foot (73630) provided on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facial gender confirmation surgery.

You asked the Plan to pre-approve facial gender confirmation surgery. You say that the requested procedures are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedures are cosmetic surgery and not a Medicare benefit.

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 facial gender confirmation surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the World Professional Association for Transgender Health states that when patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated. In this case, the medical record indicates that the enrollee has gender dysphoria. The record indicates that the enrollee has bipolar disorder, partially in remission, and requires psychiatric referral. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facial gender confirmation surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve facial gender confirmation surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you want to see this provider. The Plan denied your request. The Plan says the provider is out-of-network
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantable loop recorder.

You asked the Plan to pre-approve the implantable loop recorder. You say that an implantable loop recorder
will be helpful to determine your next step. Please reconsider the decision for your implantable loop recorder.
The Plan denied your request. The Plan says the request for the implantable loop recorder is not medically
necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the implantable loop recorder. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in this case the enrollee has documented atrial fibrillation. The record
indicates that the recorder was requested to monitor the enrollee post ablation. The elements of the coverage
rule are not satisfied. The requested service is not recommended.

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 implantable loop recorder have not been met. Therefore, we decided that the
Plan does not have to pre-approve the implantable loop recorder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3346) for tooth # 8 provided on October 29, 2020.

You asked the Plan to pay for the dental service. You say that you had pain in tooth #8. You say that it was important for you to save the tooth. You also say that you are on a fixed income and need help with this bill. The Plan denied your request. The Plan says retreatment of a previous root canal is not listed as a covered service.

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 pay for the retreatment of a previous root canal (D3346) for tooth # 8 provided on October 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on May 26, 2020.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says the
documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to
justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical
therapy provided on May 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation of physical therapy, typically 20 minutes (CPT code 97161), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee continues to be limited with active range of motion (AROM), passive range of motion (PROM), and strength causing impairments that are impacting the enrollee's quality of life. You state the therapy will help to avoid contracture and weakness of the right shoulder. The Plan denied your request. The Plan says the enrollee's function has improved, the enrollee has reached reasonable goals for daily tasks, and the enrollee (or their care giver) can continue with the home program the enrollee has learned. The Plan states that more skilled treatment is not needed at this time.
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 physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the patient's condition. Based on the available records after 24 physical therapy sessions, the enrollee appears to have improved with therapy to the point of being able to manage basic activities of daily living. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 not been met. Therefore, we decided that the Plan does not have to pre-approve evaluation of physical therapy, typically 20 minutes (CPT code 97161), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee's age and the records provided support the need for an inpatient admission. The Plan denied your request. The Plan says the care needed could be provided without an inpatient stay. The Plan says that the enrollee does not meet any of the requirements for an inpatient stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found a total knee arthroplasty has been approved. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under common procedural terminology (CPT) code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the does not record show that at the time of inpatient admission the admitting physician reasonably expects that the enrollee's necessary hospital care will span two midnight.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravascular ultrasound services coded 37253 provided
on

You asked the Plan to pay for the intravascular ultrasound services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

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, the CPT Code Manual definition of code 37253 is intravascular ultrasound (noncoronary vessel)
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure).

We find that CPT code 37253 is not supported in the medical record. Specifically, two units of this code were
billed. The operative report did not include documentation of intravascular ultrasound (noncoronary vessel)
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and
interpretation, for each additional noncoronary vessel (listed separately in addition to code for primary
procedure), for the amount of units requested. Based on this information, we decided that Medicare rules for
coverage of the intravascular ultrasound services have not been met. Therefore, we decided that the Plan does
not have to pay for the intravascular ultrasound services coded 37253 provided on
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on November 3, 2020.

You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support medical necessity for ambulance transport.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ground mileage and emergency ambulance transport. Our reviewer says that the documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee. Our physician reviewer found the review has determined that the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care.

Our reviewer found that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on November 3, 2020. Our physician reviewer also found that the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on November 3, 2020. 

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 ground mileage and emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on November 3, 2020.
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 enrollee needs longer appropriate care. The Plan denied your request. The Plan says there is no documentation that the enrollee will benefit from and improve with LTACH management.

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. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on June 12, 2020.
You asked the Plan to pay for the therapeutic exercises. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression
(PILD).

You asked the Plan to pre-approve PILD. You say that the services are necessary. The Plan denied your
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 PILD. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the
medical necessity of this request as an exception. Therefore, the request for percutaneous image-guided lumbar
decompression at L3-4 and L4-5 levels 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 PILD have not been met. Therefore, we decided that the Plan does not have to
pre-approve percutaneous image-guided lumbar decompression (PILD).