Persius/hicric huggingface dataset:
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.

Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.

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 pre-approve acute inpatient hospital care.

Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the provided documentation did not reveal an indication that you would have a higher risk of complication or prolonged recovery. There was no indication that you would require hospitalization that would likely cross 2 midnights. 

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. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on October 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections (J7325).

You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.

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 Synvisc-One. Our reviewer says that Synvisc-One is not medically necessary. Our physician reviewer found the record shows now trial of the plan preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections (J7325).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertebral corpectomy services coded 63081 and 63082
provided on December 8, 2020.

You asked the Plan to pay for the vertebral corpectomy services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT codes 63081 and 63082 are not supported in the medical record. Specifically, the operative
report did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection),
using an anterior approach with decompression of spinal cord and/or nerve root(s), for a single cervical
segment; therefore, code 63081 cannot be verified. The operative report did not include documentation of a 
partial or complete vertebral corpectomy (vertebral body resection), using an anterior approach with
decompression of spinal cord and/or nerve root(s), for each additional cervical segment (listed separately in
addition to code for primary procedure); therefore, code 63082 cannot be verified.

Based on this information, we decided that Medicare rules for coverage of the vertebral corpectomy services
have not been met. Therefore, we decided that the Plan does not have to pay for the vertebral corpectomy
services coded 63081 and 63082 provided on December 8, 2020.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

Medically necessary services can be provided in a different level of care. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with accessories.

You asked the Plan to pre-approve Group 2 power wheelchair. You say that the enrollee can safely operate this power wheelchair and it will improve her ability to perform MRADLs. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this power wheelchair will not afford the enrollee the ability to perform activities of daily living and is therefore not medically necessary.

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 Group 2 power wheelchair. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested Group 2 power wheelchair. Our physician reviewer found there is documentation that the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living (MRADLs). The enrollee's mobility deficit cannot be helped by the use of a cane or walker, but there is no documentation as to why the enrollee's care and mobility deficit cannot be managed by a tilt-in-space manual wheelchair which has been recommended by the independent physical therapy evaluation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 2 power wheelchair have not been met. Because the Group 2 power wheelchair is not covered, the requested accessories are also not covered. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve service dog support items.

You asked the Plan to pre-approve service dog support items. You say that these dogs are medically necessary emotional support. The Plan denied your request. The Plan says there is no ADA certification for a service dog.

The Plan must follow Medicare rules. Medicare does not cover service dog supplies; therefore, the Plan's rules apply in this case. The Plan rules state that this allowance is for the purchase of predetermined supplies for a qualifying ADA service dog. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of service dog support items have not been met. Therefore, we decided that the Plan does not have to pre-approve service dog support items.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation 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 this service is still being studied in clinical trials for efficacy in the treatment of knee 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 this is still an experimental and investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Contour Next Test Strip.

You asked the Plan to pre-approve Contour Next Test Strip. You say that this service is medically necessary. The Plan denied your request. The Plan says that the requested test strips are not the Plan's preferred brand.

The Plan follows Medicare rules. Medicare rules say that the Plan may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the conditions are met 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 Contour Next Test Strip. Our reviewer says that the requested items are medically necessary and reasonable. Our physician reviewer found the 670 g Medtronic pump links with the Contour Next Meter so that the blood glucose data goes directly to the pump. Although it is technically possible to use another meter and enter in the blood glucose data, it is standard of care to use the meter that works with this system to make sure the blood glucose data is transmitted correctly and efficiently.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour Next Test Strip have been met. Therefore, we decided that the Plan has to pre-approve Contour Next Test Strip.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services rendered on March 30,
2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that PT claims must be billed with the -GP modifier.

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required -GP
modifier. 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 pay for the physical therapy (PT) services
rendered on March 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on December 17, 2020.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 Plan contract specifically states that outpatient mental health care requires prior authorization both in and out of network. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health care provided to the enrollee on December 17, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of a hip fracture and non-surgical management of a tibial plateau fracture after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Zilretta.

You asked the Plan to pre-approve Zilretta. You say that Zilretta is a long-term solution for your knee pain. The Plan denied your request. The Plan says the denial of authorization for Zilretta is correct, because the Plan requires a trial of at least one other intra-articular corticosteroid before it will approve Zilretta.

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 Zilretta. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Zilretta. Our physician reviewer found you have tried and failed one other intra-articular corticosteroid Kenalog. However, repeat administration of Zilretta is not recommended as the efficacy of repeat administration has not been demonstrated.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a consultation visit provided on April 20, 2020.

You asked the Plan to pay for consultation visit. You say that the enrollee could not choose an in-network provider because no other provider was allowed into the facility during the COVID-19 pandemic. The Plan denied your request. The Plan says the denial of payment for this service is correct, because documentation was not submitted to support the billed service.

The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information to determine whether payment is due for a claim.

We looked at the file and Medicare rules. No medical records were submitted to prove that the billed service took place on date of service April 20, 2020. Without this information, you have not submitted sufficient information to support payment of this claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of consultation visit have not been met. Therefore, we decided that the Plan does not have to pay for a consultation visit provided on April 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on
January 6, 2021.

You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you have never
been charged so much for a stress test in the past and disagree with the charges. 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 $200
copayment for each advanced imaging service.

You have been asked to pay a $200 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on January 6, 2021.