Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services with blood draw at home (36415).
You asked the Plan to pre-approve home health services with blood draw at home. You say that the services are necessary due to your advanced age and physical limitations. 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. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services with blood draw at home. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The documentation does not reveal that you have other skilled nursing needs such as complex wound care therefore the request for a skilled nurse for venipuncture is 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 home health services with blood draw at home have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services with blood draw at home (36415).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have a history of spine surgery with chronic neck and low back pain. There is no upper extremity weakness. A physical examination did not note any abnormal findings. There is no plain imaging of the thoracic spine. The MRI is not reasonable or medically necessary based on the submitted documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with computed tomography (CT) scan of the skull to thigh (78815).
You asked the Plan to pre-approve a PET CT scan of the skull to thigh. You say that the service is 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 PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET CT scan of the skull to thigh. Our reviewer says that the service is not medically necessary. Our physician reviewer found guidelines do not support PET imaging for the initial staging of prostate cancer. A Choline C-11 PET scan is an imaging test used to help detect sites of recurrent prostate cancer despite treatment. It may be used when other imaging hasn't been helpful. The review has determined that the member does not have an indication for which a PET CT scan can be covered 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 a PET CT scan of the skull to thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with computed tomography (CT) scan of the skull to thigh (78815).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy administrative services as identified by CPT Code S9500.
You asked the Plan to pre-approve home infusion services. You say that denial will require the enrollee to travel in to the office. The Plan denied your request. The Plan says the requested code is not covered under Medicare or the enrollee's plan.
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 S9500 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9500 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pre-approve home infusion therapy administrative services as identified by CPT Code S9500.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power-operated scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary, as you do not want to be confined. The Plan denied your request. The Plan says this 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 scooter. Our reviewer says that the requested scooter is not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet the criteria for this scooter, as you are still mobile. You transfer and ambulate short distances independently. It is difficult to assess why your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair without reviewing recent therapy notes. All that was provided was a power wheelchair assessment. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power-operated scooter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued physical therapy for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee does not meet themedical necessity criteria for the continuation of rehabilitative physical therapy services.The Planmust follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the goals of treatment are unchangedfor an unknown period of time. At this point, either the enrollee would be expected to have achieved his goals or they would have been modified to reflect achievable and realistic goals within a reasonable timeframe. Ongoing skilled therapy services are not medically necessary. Given the number of treatments already provided, he appears to have reached a plateau in improvement. Physical therapy provided in excess of what is medically necessary may promote dependence on therapy provided treatments rather than a regularly performed home exercise program and given the number of treatments already provided he should be able to perform a self-directed home exercise program incorporating the therapeutic content being provided by his physical therapy. If there is an indication for specialized equipment then a gym membership could be considered. A daily exercise program would be expected to meet this member's needs rather than weekly therapy sessions. His primary care provider can assess whether any deterioration occurs and request additional therapy if appropriate.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 Plandoes not haveto pre-approvecontinued physical therapy 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 the enrollee will continue to decline without the proper treatment. The Plan denied your request. The Plan says the enrollee does not have any wound complications, cardiac or respiratory problems.
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 The enrollee is weak and deconditioned. She walks with a walker at baseline. Presently she is walking 30 feet with a rolling walker and gait belt and stand by assistance. She is requiring minimum assistance with bed mobility, and her upper extremity and lower extremity range of motion is within functional limits. 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 does not require treatment in an intensive rehabilitation therapy program. This enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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 a safety strap for a wheelchair.
You asked the Plan to pre-approve the safety strap. You say that this is medically necessary, and the enrollee's health is deteriorating without the safety strap. The Plan denied your request. The Plan says the criteria for this strap are not met.
The Plan must follow Medicare rules. Medicare rules say that safety belt for a wheelchair is covered when there is upper body weakness, instability or muscle instability which require a belt to allow for proper positioning. There is no documentation of any of the above conditions to justify the need for a safety belt in this case. Therefore, we decided that the Plan does not have to pre-approve a safety strap for a wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto for the enrollee.
You asked the Plan to pre-approve Entresto. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Entresto for the enrollee.
Benefits for Entresto 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 27, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 27, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the visual field exam. We decided that the Plan does not have to waive the copayment for the eye exam.
You asked the Plan to waive the copayment for the visual field exam and eye exam. You say that time ran out to complete the tests so you had to return the next day. You say that the copayment should be refunded. The Plan says that the copayments applied correctly.
We decided that the Plan has to waive the copayment for the visual field exam.
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 $0 for Medicare-covered diagnostic tests in your doctor's office or in an outpatient hospital setting. The visual field exam is considered a diagnostic test. Therefore, we decided that the Plan has to waive the copayment for the visual field exam.
We also decided that the Plan does not have to waive the copayment for the eye exam.
Your contract with the Plan clearly says that you must pay a $50 copayment for routine eye exams or Medicare-covered non-routine eye exams. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient hospital admission
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the Medicare coverage criteria has not been met.
The Plan follows 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 midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights 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 the inpatient hospital admission. Our reviewer says that this is not medically necessary Our physician reviewer found the enrollee is to undergo an Arthoplasty, which is not on the inpatient only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities pre-procedure, which are reasonably expected to necessitate a prolonged (i.e. two midnight) stay. The enrollee should present for, undergo, and be monitored following the procedure as an outpatient. Should complications arise necessitating a prolonged stay, the enrollee can be converted to inpatient status, at that time, under the two midnight rule. 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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient hospital admission
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation did not support the medical necessity for these laboratory services.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided the requested molecular genetic testing is not medically reasonable and necessary. There is no personal history or diagnosis of cancer or any reported suspicion of active cancer. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system, and a power seat elevation system for the enrollee's wheelchair.You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to control the power options using their own switches. The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.The file shows that a power seat elevation system was requested. We looked at the file and the rules. A power seat elevation feature is non-covered because it is not primarily medical in nature. Based on this information, we decided that the Medicare rules for coverage have not been met.The file also shows that an expandable control system was requested. 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 items. Our physician reviewer found that the documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength and function is sufficient to control the power options with their separate switches already included with the approval of the power options.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 items have not been met.Therefore, we decided that the Plan does not have to pre-approve an expandable control system, and a power seat elevation system for the enrollee's wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve various power wheelchair accessories.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these items do not serve a primarily medical purpose and are not allowed.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal (seat elevator, power standing system, USB charger, phone holder, color kits, LED light kit) do not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve various power wheelchair accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 26, 2019.
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 procedure code 01402 is not supported.
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 01402 is anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty. We find that CPT code 01402 is not supported in the medical record. Specifically, the documentation does not indicate that anesthesia for an open or surgical arthroscopic procedure on the knee was performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 12, 2019.