Persius/hicric huggingface dataset:
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 a LTACH admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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 is receiving necessary services at an acute care hospital and is at an appropriate level of care. The acute care hospital is able to provide all of the services the enrollee requires. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility,or home with home health 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjections.You asked the Plan to pre-approveinjections. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain indications.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the documentation does not support that the requested injection services are medicallyreasonable or necessary. Our physician reviewer found the enrollee has an unspecified cervical disc disorder, chronic neck pain due to cervical spondylosis, cervical radiculopathy, cervical spinal stenosis, a history of chronic migraine headaches, and schizophrenia. A cervical MRI revealed multilevel cervical spondylosis with spinal and foraminal stenosis most pronounced at C5/6 and C6/7. The documentation stated that the enrollee underwent physical therapy for cervical pain 10 years ago at the VA for numerous sessions. Physical therapy provided some relief. The enrollee has a documented history of cervical radiculopathy. The documentation supports that the requested injections are not considered the standard of care for the treatment of the enrollee's condition. Therefore, the enrollee does not meet criteria for the requested servicesWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have not been met.Therefore, we decided that the Plan does not have to pre-approveinjections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that the services are 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. 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. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is requiring ongoing care and supervision. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled and warranting the services requested. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant related procedures (D6010, D6057, D4263, D4365) and 2 additional alveoloplasty procedures (D7311).You asked the Plan to pre-approve implant related procedures and 2 additional alveoloplasty procedures. You say that the services are necessary.The Plan denied your request. The Plan says the benefit for the oral surgery procedures has been exhausted and implant related procedures are not a covered benefit.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 pre-approve implant related procedures (D6010, D6057, D4263, D4365) and 2 additional alveoloplasty procedures (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories (E2377, E0955, E2361, E2313, E1012, K0108, E1007, E2602, E1028, E2311, E1028). You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this is necessary to meet the enrollee's needs.The Plan denied your request. The Plan says the enrollee's mobility limitation is not due to a neurological condition, myopathy, or congenital skeletal deformity.The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair is covered only if the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.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  and accessories. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found based on the medical records provided the records do not show that the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.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  and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories (E2377, E0955, E2361, E2313, E1012, K0108, E1007, E2602, E1028, E2311, E1028).
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 is receiving appropriate care at the current acute care facility.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. 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 found that the enrollee's condition does not meet Medicare criteria for LTACH 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 12, 2019.You asked the Plan to pay for lab test. You say that you are requesting payment for this claim.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the provider did not furnish necessary information to the Plan when requested.The Plan must follow Medicare rules. Medicare rules say that the provider must furnish sufficient information to the Plan to determine whether payment is due for a claim. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.We looked at the file and Medicare rules. The documentation submitted does not include medical records or a valid physician order to support the lab test billed. The plan requested this information, but it was not provided. Without this documentation, you have not furnished sufficient information to the Plan to justify payment of this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are required to aid in treatment of lymphedema. The Plan denied your request. The Plan says are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health care (G0299, G0300).
You asked the Plan to pre-approve continued home health care. You say that you need home health services to help you get through your cancer. The Plan denied your request. The Plan says your medical issues have stabilized.
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 continued home health care. Our reviewer says that the requested services do not meet criteria for coverage. Our physician reviewer found the records do not indicate that you are home-confined or need skilled services. Your current needs are custodial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health care (G0299, G0300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve darbepoetin alfa. You asked the Plan to pre-approve these services. You say that the services are medically necessary due to persistent anemia. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 enrollee is no longer on any chemotherapy. Darbepoetin alfa should only be used in anemic patients currently receiving myelosuppressive chemotherapy and should be discontinued after the completion of a chemotherapy course. The drug is therefore not safe and effective or medically necessary for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve darbepoetin alfa.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing.You asked the Plan to pre-approve these services. You say that the testing is needed.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 submitted records show that you have a diagnosis of Parkinson's disease and had a deep brain stimulator implanted. Your doctor is asking for the neuropsychological testing to evaluate your cognition. This can be evaluated with a thorough comprehensive clinical evaluation, which you have not yet received. The neuropsychological testing 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 neuropsychological testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 11, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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 and the referring physician are not network providers with the Plan. 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 for laboratory services provided on
December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that SNF care would help the enrollee get back on his feet. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 13, 2020 after a fall with a facial fracture. He received oral medications and had stable vital signs. He received physical, occupational, and speech therapy in the hospital and needs maximum to total assistance with mobility and activities of daily living. He has no skilled nursing needs and does not require skilled nursing on a daily basis. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran outpatient surgery provided by an in-network provider on November 26, 2019.You asked the Plan to waive the coinsurance for an outpatient surgery. You say that this coinsurance is too high. The Plan denied your request. The Plan says the correct coinsurance has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 25% coinsurance for outpatient hospital services/in-network/surgery services. You have been asked to pay less than your 25% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $29,797.39. The total coinsurance is $7,449.35 ($29,797.39 x 25% = $7,449.35). The total amount you are being asked to pay the lesser amount of $6,110.53. An outpatient surgery falls within the outpatient hospital services/in-network/surgery services benefit category. 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 coinsurance for an outpatient surgery provided by an in-network provider on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits with a Naturopath.You asked the Plan to pre-approveoffice visits with a Naturopath. You say that the services are necessary.The Plan denied your request. The Plan says the services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services.Therefore, we decided that the Plan does not have to pre-approveoffice visits with a Naturopath
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on January 9, 2020 to January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also 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 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 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 an office visit and physician services provided on January 9, 2020 to January 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that  the  Plan  does not  have  to pay  for physician's  services  provided  on February  10, 2020.You asked the  Plan  to pay  for the  physician's  services. The  Plan  denied your  request.  The  Plan  says that you must  receive  care from  in-network  providers  with  the  exception  of emergency  or urgent  care, dialysis  while temporarily  out of the  plan's  service  area or if  the care cannot  be provided  with  an in-network  provider,  which requires  prior  authorization  from  the  plan. 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  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 for  physician's  services  provided  on February  10, 2020.