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

We decided that the Plan does not have to pre-approve the Vertiflex device and surgery for the enrollee.

You asked the Plan to pre-approve the Vertiflex device. You say that this device and surgery are medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not cover experimental devices. 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 Vertiflex device. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device and surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology treatment with an out-of-network
tertiary level of care provider.
You asked the Plan to pre-approve specialist services. You say that you need this higher level of care. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because you do not
require tertiary level of care and can be treated by an in-network community level ophthalmologist.
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 specialist services. Our reviewer says
that you do not meet the Medicare criteria for treatment with the requested out-of-network tertiary level of care
provider. Our physician reviewer found the record indicates that you have macular degeneration and a cataract.
The records provided indicate that the Plan has arranged an appointment with an in-network ophthalmologist.
You do not require care that is not available within the Plan's network.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of specialist services have not been met. Therefore, we decided that the Plan does
not have to pre-approve ophthalmology treatment with an out-of-network tertiary level of care provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on January 18, 2021.
You asked the Plan to waive the copayment for these services. You say that you weren't seen by the provider and only went in for a COVID test. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist visit for Medicare-covered benefits.
Review of the file shows that you received specialist services on January 18, 2021. Per the contract with the Plan, there is a $40 copayment for each specialist visit for Medicare-covered benefits. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $28.22. Given that the allowed amount was less than the $40 copayment, you have been asked to pay $28.22 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allograft injection (Q4206).
You asked the Plan to pre-approve the injection. You say that the injections are medically necessary. The Plan
denied your request. The Plan says this procedure is experimental and non-covered.
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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found current literature does not provide sufficient evidence to strongly support the use of stem cell treatments
for this patient'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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve an allograft injection (Q4206).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that the requested drug is reasonable and necessary because the enrollee has tried Humira. The Plan denied your request. The Plan says the requested drug is not medically necessary as the enrollee has not tried Stelara.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Entyvio. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the enrollee has elevated body mass index (BMI) and bipolar disorder, and a history of colonic adenoma, status post appendectomy, hysterectomy, Caesarean section, and hernia repair. The enrollee was diagnosed in 2000 with ulcerative colitis. The enrollee was clinically responsive to and well tolerated Humira. However, the enrollee reported having discontinued Humira in response to suspected drug-associated lupus. Available records do not support trial and failure by the enrollee of Stelara, nor intolerance to the drug which is FDA-indicated for Appellant'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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Entyvio (J3380).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 4, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 4, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular neurostimulator device.
You asked the Plan to pre-approve an auricular neurostimulator device. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that an auricular peripheral nerve stimulator is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that this is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve an auricular neurostimulator device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee is a 90-year-old woman with a
history of hypertension, who was admitted to the hospital on May 17, 2021. While the enrollee is expected to
benefit from skilled therapy services, the documentation does not support that those services are needed on a
daily basis on an inpatient basis in a skilled nursing facility. In addition, skilled nursing services are not
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the standard wheelchair rented on November 12,
2020, from a non-Medicare certified provider.

You asked the Plan to reimburse you for the standard wheelchair. You say that you needed the wheelchair after
a surgery. The Plan denied your request. The Plan says this supplier is not participating with Medicare.

Medicare rules say that no Medicare payment may be made to a beneficiary for items provided directly by a
provider who is not eligible to take Medicare payment.

The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided
that the Plan does not have to reimburse you for the standard wheelchair rented on November 12, 2020, from a
non-Medicare certified provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is at a custodial or maintenance level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. You do not not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 or necessary. Our physician reviewer found the last clinic visit on 5/6/21 showed a negative neurological exam. Thus, there are no red flags to mandate immediate MRI without a six week trial of physical therapy. There are no details concerning physical therapy in the records. 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 MRI of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this request is medically necessary. The Plan denied your request. The Plan says Vertiflex surgery is investigational and experimental.
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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a history of heart disease, diabetes, and dementia, who is being treated for osteomyelitis of the 5th metatarsal. The enrollee is receiving antibiotics. Based on the documentation provided, there are no skilled nursing services or skilled therapy services. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has right knee osteoarthritis. Genicular RFA is considered experimental/investigational in nature and the subject of ongoing clinical trials. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation (RFA) of the lateral sacral branches provided on December 9, 2020.

You asked the Plan to pay for the RFA. 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 pay for the RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the procedure was 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 the RFA have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation (RFA) of the lateral sacral branches provided on December 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received at home or at another kind of facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because this level of care is medically necessary. The Plan denied your request. The Plan says you not have complex medical care that requires physician oversight three times per week, your medical conditions are stable and your therapy is routine.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. 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.