Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
You asked the Plan to pre-approve 5 additional physical therapy visits. You say that the additional 5 physical therapy visits are medically necessary. The Plan denied your request. The Plan says the additional 5 physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 5 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and approved an additional 10 visits and the records do not demonstrate the outcome of the additional approved visits and that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program. The additional requested therapy of 5 visits is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan 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 5 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left shoulder.

You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says an MRI 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 an MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 66-year-old male being treated for adhesive capsulitis left shoulder. Enrollee notes worsening left shoulder pain from an injury. He notes the symptoms have worsened to a point that he can barely move his arm. Exam reveals terrible shoulder range of motion. He can externally rotate to about 10 degrees, internally rotate fully to reach belt line. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive conservative care measures. Therefore, the requested MRI of the left shoulder is 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder orthosis provided on October 20, 2020.
You asked the Plan to pay for the shoulder orthosis. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 shoulder orthosis. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a shoulder orthosis provided on October 20, 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. The Plan denied your request. The Plan says the enrollee does not meet criteria for a LTACH.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: 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 the admission into an IRF is medically necessary. The Plan denied your request. The Plan says the member can safely receive services in 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 there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be provided in a lower level of care. This means that admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Sincerely,
Office of the Project Director Medicare Managed
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided at the DRG 193 rate.

You asked the Plan to pay for the inpatient services at the DRG 193 rate. You say that the Plan should pay the claim as DRG 193. The Plan denied your request. The Plan says the billed DRG 193 Simple Pneumonia and Pleurisy with MCC is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 193 is defined as Simple Pneumonia and Pleurisy with MCC.

In this case, you billed the services provided with DRG 193 Simple Pneumonia and Pleurisy with MCC. 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 inpatient services at the DRG 193 rate. Our reviewer says that a review of the medical records submitted did not validate J96.01 as the diagnosis for this admission. The secondary diagnosis code is one of the determining elements for MS DRG assignment and payment. Our physician reviewer found the review has determined that the claim was not submitted with the appropriate DRG for this case. The review supports DRG 194, Simple Pneumonia and Pleurisy with CC is more appropriate. The records did not validate Acute respiratory failure with hypoxia (J96.01) as the diagnosis for this admission.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 193, J96.01. Therefore, we decided that the Plan does not have to pay for the inpatient services provided at the DRG 193 rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9612).
You asked the Plan to pre-approve the services. You say that you are getting twenty teeth pulled, and the pain will be too much. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 dental services (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7953, D4266).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services (D7953, D4266).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that providers noticed an issue with your pulmonary
system and recommended a CT scan within 6 months. You say that you are concerned and want to have the CT
scan. The Plan denied your request. The Plan says the requested CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the
requested CT scan is not medically necessary. Our physician reviewer found no office notes were submitted for
review. Our physician reviewer found that there is no documentation of an indication for the requested
computed tomography scan. There is no documented medical reason why other types of radiologic scans could
not be used to evaluate the enrollee's symptoms. There is no evidence that the enrollee's clinical condition
meets the criteria for coverage of the requested CT scan.
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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve computed tomography (CT) 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 the services are medically necessary. The Plan denied your request. The Plan says the enrollee's 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 there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation 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 IRF care have not been met. Specifically, the enrollees' medically necessary services can be provided at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole-body bone scan.
You asked the Plan to pre-approve a whole-body bone scan. You say that the requested whole body bone scan
is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not
show that the service in dispute is medically necessary.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve a whole-body bone scan. The records show that the beneficiary
is enrolled in the BRACELET clinical trial and that the requested scan is being ordered to assess the response
to treatment associated with this clinical trial. The Plan does not cover routine costs associated with qualifying
clinical trials. Therefore, we decided that the Plan does not have to pre-approve a whole-body bone scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia (J0897). You say that receiving the injection is medically necessary. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had a contraindication or intolerance to zoledronic acid.

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 Prolia (J0897). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the patient has not tried and failed the required drug. There is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. The patient does not have a history of osteoporosis related fracture. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient surgery percutaneous transcatheter closure of the left atrial appendage with endocardial implant (33340).
You asked the Plan to pre-approve inpatient surgery percutaneous transcatheter closure of the left atrial appendage with endocardial implant. You say that the service is medically necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee is enrolled in a CMS approved clinical study/registry/ trial.
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 inpatient surgery percutaneous transcatheter closure of the left atrial appendage with endocardial implant. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee is enrolled in a CMS approved registry/trial/study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient surgery percutaneous transcatheter closure of the left atrial appendage with endocardial implant have not been met. Specifically, there is no documentation that the enrollee is enrolled in a CMS approved clinical study/registry/ trial. This means the service does not meet the criteria for coverage and is found to be not medically necessary or reasonable in this case. Therefore, we decided that the Plan does not have to pre-approve inpatient surgery percutaneous transcatheter closure of the left atrial appendage with endocardial implant (33340).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says the services can be obtained in an observational level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the patient does not appear to have comorbidities or expected complexity in the surgery or recovery that might require at least 2 midnights of hospital 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 acute inpatient hospital care have not been met. Specifically, the member can obtain the medically necessary care at an observational level. This means admission in to an inpatient hospital is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
You asked the Plan to pre-approve the partial dentures. You say that the enrollee needs a new maxillary partial denture and mandibular partial denture. The Plan denied your request. The Plan says these services are allowed one time in 5 calendar years. The Plan also says that the enrollee has already had these services within the past 5 years, and have reached the limits for these services.
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, maxillary dentures and mandibular dentures are each limited to 1 per 5 calendar years. The record shows that the enrollee received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on November 24, 2020, and the enrollee's denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for tooth #'s 3 & 5.

You asked the Plan to pre-approve the pontic and retainer crowns. You say that the three unit bridge is necessary. The Plan denied your request. The Plan says the documents failed to demonstrate a specific special needs or medical condition (physical or neurological) that would preclude the use of a removable partial denture.

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 pontic and retainer 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 pontic and retainer crowns. Our reviewer says that the bridge is not medically reasonable and necessary. Our physician reviewer found there has been no submission of the required documentation for consideration of the bridge. Our reviewer also found that although the prosthesis may be reasonable in the circumstances, the Plan criteria has not been met and the procedure is not medically necessary.

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 pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for tooth #'s 3 & 5.