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 LTACH services are medically necessary. The Plan denied your request. The Plan says the criteria for an LTACH are not met, and you are receiving appropriate care in the current acute 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. Our physician reviewer found you appear to be improving but are not yet stable for transfer. You require only short-term additional acute care services which can be safely administered in the current facility. You do not require services at the LTACH that are not already available at the current facility. Therefore, the request for LTACH services will be considered not 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crutch substitute (E0118).

You asked the Plan to pre-approve the crutch substitute (E0118). You say that you need to get a knee scooter so you are able to go to your doctor's appointments and you can cause harm to yourself by falling due to having no balance. The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch substitutes.

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 crutch substitute (E0118). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the provided documentation, there was description of the enrollee not being able to use crutches to ambulate safely to help justify the use of a rolling knee walker. Therefore, without sufficient support made for this request, it will be considered not 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 the crutch substitute (E0118) have not been met. Therefore, we decided that the Plan does not have to pre-approve the crutch substitute (E0118).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel (81455).
You asked the Plan to pre-approve a targeted genomic sequence analysis panel. You say that this could help
many people. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under the
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and
will be denied automatically as not medically necessary.
We looked at the file and Medicare rules. The requested testing is unlikely to impact therapeutic decision making
and is not considered medically necessary. Based on this information, we decided that Medicare rules
for coverage of a targeted genomic sequence analysis panel have not been met. Therefore, we decided that the
Plan does not have to pre-approve a targeted genomic sequence analysis panel (81455).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on January 15, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $30 copayment for specialist services. You have been asked to pay a $30 copayment for specialist services. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 copayment for specialist services provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

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 criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not check your blood sugars three or more times per day and do not inject insulin three or more times per day. 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 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this is not covered for enrollees who do not use insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve 5 treatment sessions of stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve stereotactic body radiation therapy. You say that please find the medical records and physician notes which provide evidence as to the medical necessity of radiation therapy treatments The Plan denied your request. The Plan says that the requested service does not meet medical necessity.

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 stereotactic body radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has oligometastatic. This enrollee's ECOG (Eastern cooperative oncology group) status is described as 1. SBRT can be considered an accepted standard of care for this enrollee. My decision is therefore favorable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stereotactic body radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve 5 treatment sessions of stereotactic body radiation therapy (SBRT).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on March 2, 2021.

You asked the Plan to pay for a bone replacement graft. You say that you were referred to this provider by an in-network provider and the Plan should pay for the service. The Plan denied your request. The Plan says the service at issue is 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 pay for a bone replacement graft (D7953) provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an extraction (D7210), and an unspecified preventive procedure (D1999) provided on April 8, 2021.
You asked the Plan to pay for a limited oral evaluation, an extraction, and an unspecified preventive procedure. You say that the services were necessary. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, an extraction, and an unspecified preventive procedure have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an extraction (D7210), and an unspecified preventive procedure (D1999) provided on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on April 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.

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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". 

We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not show that 30-74 minutes of critical care services were provided on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on April 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on February 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 30-74 minutes of critical care services were provided on the date of service in question.
Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 30, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for a drug test. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a drug test provided on September 30, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on April 16, 2021.
You asked the Plan to pay for the pathology services. You say that the patient went to an in-network provider, so this claim should be paid. The Plan denied your request. The Plan says it has not paid anything towards these pathology services because the enrollee has not yet met their annual deductible. The enrollee is responsible for paying the annual deductible before the Plan will pay for care.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible that applies to out-of-network lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies to out-of-network lab services. This cost sharing is a contractual obligation that had not been met at the time the pathology services were received on April 16, 2021. Therefore, we decided that the Plan does not have to pay for the pathology services provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on December 11, 2020.
You asked the Plan to pay for the definitive drug testing. You say that this testing should be covered. The Plan denied your request. The Plan says the incorrect POS code is reported.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not support POS code 81, as the sample is not shown to be taken directly by the laboratory. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) from L3-S1 for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a recent medial branch block to confirm the source of the pain.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee previously underwent a lumbar RFA on 11/22/2019 with good results. However, this was performed by an "outside provider." There is no documentation of a recent diagnostic medial branch block to confirm the source of the pain. This is required to repeat the RFA. The enrollee does not meet the criteria for this request. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) from L3-S1 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on March 12, 2021.
You asked the Plan to pay for the services provided. You say that the tests were ordered by the referring physician. The Plan denied your request. The Plan says genetic screening testing is not a Medicare benefit for the diagnoses listed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The records provided do not show the results of the testing would be used in the management of a specific medical problem. The services provided were requested solely for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on March 12, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for outpatient office visit services.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says it is the responsibility of the enrollee and provider to verify benefits and coverage prior to rendering, receiving, or referral of 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for outpatient office visit services.
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 are a risk of falling and are not safe to go home without additional care and improvement. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.