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

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have recurrent breast cancer that was treated in 2019. You have had at least four PET scans. PET scans are not indicated for surveillance. The repeat PET scan is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 21, 2018, to May 2, 2018 and May 12, 2018, to May 20, 2018.
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's condition no longer required daily skilled services at an inpatient SNF 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 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 April 21, 2018, to May 2, 2018 and May 12, 2018, to May 20, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana.
You asked the Plan to pre-approve Invokana. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B 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 Invokana.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says your request for approval of admission to a LTACH does not meet the requirements for approval.
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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer found that there are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the Health Plan. Our physician reviewer also found that consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power leg elevation system.
You asked the Plan to pre-approve a Group 3 power wheelchair (K0856) with power leg elevation system (E1012). You say that you need a Group 3 power wheelchair with power leg elevation system. The Plan denied your request. The Plan says the there is no documentation to support that you cannot perform a functional weight shift, have poor midline stability or the chair is appropriate to your environment.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 3 power wheelchair (K0856) with power leg elevation system (E1012). Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found the documentation does not support that the enrollee meets all of the criteria for coverage for the Group 3 power wheelchair (K0856) with power leg elevation system (E1012). The documentation does reveal that the enrollee has a personal mobility deficit that impairs participation in MRADLs in the home. The enrollee's mobility deficit is currently helped by a walker. Additionally, the physician visit is a telehealth visit and there is no documentation of a detailed neuromuscular exam indicating why the enrollee is unable to propel a manual wheelchair. The documentation reveals the enrollee has the cognition to safely operate a power wheelchair but the documentation does not indicate the K0856 is medically necessary. As the documentation does not support that the enrollee meets all of the criteria for coverage for the K0856, the accompanying request for power leg elevation 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 a Group 3 power wheelchair (K0856) with power leg elevation system (E1012) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power leg elevation system.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 14, 2020.

You asked the Plan to waive the copayment for emergency care. You say that you are appealing your cost-share responsibility for the services you received due to the quality of care. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received emergency care on July 14, 2020. You are asked to pay a $120 copayment for the emergency care services. Your EOC states that enrollees must pay a $120 copayment for emergency 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 emergency care provided on July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you recommend the enrollee receive
inpatient rehabilitation in order to increase strength and mobility, as well as in an effort to restore the enrollee
to her prior level of functioning. The Plan denied your request. The Plan says your request for approval of an
IRF admission does not meet the requirements for approval.

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 the enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or
to require regular physician evaluation. Our reviewer also found that the enrollee's care needs can be met at a
lower level of care.

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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan has to pay for drug testing (G0483) provided to the enrollee on January 20, 2020.

You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says that Medicare coverage criteria were not met. We had originally decided the
Plan was correct. Our Medical Director reviewed the case a second time. At issue is coverage for Drug test(s),
definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between
structural isomers. The enrollee has a diagnosis of Long term (current) use of opiate analgesic. The Plan denied
coverage of the urine drug testing, stating that new medical records were submitted for this appeal and consist
of an unsigned order for the service date of January 20,2020. The case file contains an order form for Pain
Panel and Barbiturates/THC dated January 20, 2020, with Physician Signature on File. A Progress/Procedure
Note by the ordering physician, dated January 20, 2020 documents, "Due to the inherent risks of controlled
substance use including inadvertent misuse and intentional abuse, to monitor the patient's compliance with
prescribed pain medication, a urine specimen shall be obtained from patient today for purposes of testing for
drugs of abuse, metabolites of prescribed medications and adulterants." Therefore, the documentation supports
that the urine drug testing was 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 this testing have been met. Therefore, we decided that the Plan has to pay for drug 
testing (G0483) provided to the enrollee on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office services provided on July 20, 2020, by an in-network provider.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the coinsurance because you feel the provider misdiagnosed you. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received the specialist office services provided on July 20, 2020, by an in-network provider. You are asked to pay a $35 copayment for the services. Your EOC states that enrollees must pay a $35 copayment for each in-network specialist visit for Medicare-covered services. 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 the specialist office services provided on July 20, 2020, by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more
teeth per quadrant (D4341) of the upper left quadrant.
You asked the Plan to pre-approve the scaling and planing. The Plan denied your request. The Plan says there
are less than four teeth in the upper left quadrant.
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 scaling
and planing 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 scaling and planing. Our reviewer
says that the documentation provided does not meet the criteria for coverage for periodontal scaling (D4341) of
the upper left quadrant. Our physician reviewer found the documentation provided lacked a record of the
periodontal charting and the radiographs indicated less than 4 teeth in the quadrant. Our reviewer also found
that code D4341 requires at least four teeth in the quadrant.
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 scaling and planing have not been met. Therefore, we decided that the Plan
does not have to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341)
of the upper left quadrant.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have no skilled nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2752) for tooth #'s 7, 8, 9, and 10.
You asked the Plan to pre-approve the crowns. You say that you need your teeth to be capped because you do not want them to rot out. The Plan denied your request. The Plan says the crowns are not medically necessary. The Plan also says that these teeth can be restored traditionally.
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 crowns 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 crowns. Our reviewer says that the crowns do not meet coverage criteria. Our physician reviewer found there does not appear to be significant coronal breakdown of tooth #'s 7, 8, 9 and 10 to warrant restoration with crowns. 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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2752) for tooth #'s 7, 8, 9, and 10.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that you disagree with this denial. The Plan denied your request. The Plan says that the doctor's notes should include a recent doctor's order, and a physical examination that shows a wheelchair is right for your mobility needs.

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. 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 has not substantiated their denial. Your provider is a contract provider. A contract provider is an agent of the plan; therefore, it is the plan's responsibility to receive these records. Therefore, we decided that the Plan has to pre-approve a manual wheelchair
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for osteogenesis stimulator, low intensity ultrasound, non-invasive (CPT Code E0760) provided on February 28, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says there is no documentation that the member's right tibial (leg) fracture has failed to heal after 90 days.
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 DME. Our physician reviewer found the documentation does not support that the member has a covered indication for an osteogenesis stimulator, such as nonunion of a long bone fracture where fracture healing has ceased for three (3) or more months prior to starting treatment, failed fusion where a minimum of nine (9) months has elapsed since the last surgery, or congenital pseudarthrosis. Ultrasonic osteogenic stimulators for fresh fractures and delayed unions remains non-covered.
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 DME have not been met. Therefore, we decided that the Plan does not have to pay for osteogenesis stimulator, low intensity ultrasound, non-invasive (CPT Code E0760) provided on February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia Clickject (J0129).
You asked the Plan to pre-approve Orencia Clickject. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Orencia Clickject (J0129).
Benefits for Orencia Clickject 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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the OmniSeq Advance Targeted Panel for the enrollee.

You asked the Plan to pre-approve the panel. You say that this should be paid for. The Plan denied your request. The Plan says that this is not a recommended test, and far exceeds the recommendations of the guidelines.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 panel. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of next generation sequencing (NGS) or molecular profiling is recommended by the NCCN Guidelines for patients with endometrial cancer. Molecular analysis (eg, identification of characteristic translocations) can help classify difficult cases and provide future therapeutic targets. This enrollee has metastatic disease and is receiving first line therapy and her treating physician is planning for future recurrence. The service is 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 panel have been met. Therefore, we decided that the Plan has to pre-approve the OmniSeq Advance Targeted Panel for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's continued needs can be met through a lower 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 above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.