Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is 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 a power scooter. Our reviewer says that the documentation does not support that the requested power scooter is medically reasonable or necessary. Our physician reviewer found the documentation does not support that you have a personal mobility deficit that impairs participation in mobility related activities of daily living in the home. The documentation does not reveal why your mobility deficit is unable to be helped by a walker, cane, or manual wheelchair. There is no objective gait exam. The documentation reveals that the scooter will not fit in the home and is for out of the house; therefore, the requested K0800 will not significantly improve activities of daily living performance in the home and is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
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 you disagree with the denial. 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 you were admitted to the hospital with left hemiparesis and transferred to an inpatient rehabilitation facility (IRF). You received physical and occupational therapy in the hospital and need varied assistance with functional mobility. You need assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do 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: 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 the services are medically necessary. The
Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was
admitted to the hospital with respiratory distress. On December 7, 2020 she felt she was near her baseline and
was not in acute cardiopulmonary distress. It is documented that she may be discharged from a pulmonary
standpoint. The documentation does not support that the enrollee in this case requires services at the LTACH
that are not available at the acute care hospital where she is currently receiving care. The documentation does
not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case.
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forX-rays provided on July 16, 2020 and August 13, 2020.You asked the Plan to waive the copayments forX-rays. You say that the X-rays were for post-operative reasons so you should not owe a copayment.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 enrolleesin 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 each basic imaging service.You received X-rays on July 16, 2020, and August 13, 2020 for a total of two. X-rays are not included in post-operative visits and are subject to cost-sharing charges. Therefore, you are responsible to pay a $30 copayment per each X-ray. The total amount you owe is $30 (copayment) x 2 (X-rays) = $60.  You have been asked to pay the total copayment amount of $60 for X-rays. X-rays fall 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 copayments forX-rays provided on July 16, 2020 and August 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan doesnot have to pre-approvecontinued SNF care.You asked the Plan to pre-approvethe continued SNF care. You say that the enrollee has exhausted his 100 skilled nursing days on December 2, 2020 and at the end of his days he contracted the COVID-19 virus.The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in aSNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNFcare during the benefit period from August 14, 2020, to December 3, 2020. The Plan has at least 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvecontinued SNF care
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with a subarachnoid hemorrhage, malignant hypertension, and respiratory distress which required intubation and mechanical ventilation. She has improved and is now considered stable; however, additional short term acute care services and coordination is needed which can safely be completed at the current facility. She does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not available at the current facility or lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee cannot be adequately cared for in his current condition at a lower level of care.The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the acute care hospital.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 physician reviewer found that the enrollee was admitted to the acute hospital with a fall with muscle injury and acute kidney injury which required a short course of hemodialysis. He had respiratory failure related to COVID pneumonia which required supplemental oxygen and blood clots to the lungs and right arm. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 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. 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 lookedat 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-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on June 29, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you got your last panoramic x-ray from your dentist, but the treating provider needed to take a new panoramic x-ray. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a panoramic x-ray on February 26, 2019, and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on July 18, 2020.You asked the Plan to pay forthe dental service. You say that you changed dentists in 2020 because you were not happy with the services you received with your previous dental provider. You say that the provider's office was not aware of the frequency limit. You say that the Annual Notice of Changes (ANOC) states that you have a $0 copayment for preventive and diagnostic services. You also say that the ANOC does not say anything about the comprehensive evaluation being covered every 3 years.The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit for this service has been exceeded.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 frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on January 9, 2019, less than 3 years prior.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on July 18, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighty units of physical therapy.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says the notes do not show why care is needed 2-3 times a week for 12 weeks.
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 the therapy. 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 requested additional therapy is not generally accepted as specific
and effective therapy for your condition. You have had prior therapy for this condition, and the plan approved
an additional 32 units. Your deficit do not currently appear to require any additional therapy beyond the already
authorized therapy, or without clear indication of the remaining deficits beyond the authorized therapy. You
should be able to transition to an independent exercise program with the already authorized therapy.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve eighty units of physical therapy.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with necrosis of left toes. Recent notes show that she is stable and was recommended subacute rehabilitation for additional physical therapy. She does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not available at the current facility or lower level of care. The LTACH services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 waive the copayment fora sacroiliac joint injection provided on August 13, 2020.You asked the Plan to waive the copayment fora sacroiliac joint injection. You say that you disagree with the surgery charges and feel that you should only owe a $36 copayment.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 $50 copayment for each specialist visit. You received a sacroiliac joint injection on August 13, 2020, from a specialist. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a sacroiliac joint injection. A sacroiliac joint injection fallswithin the outpatient hospital 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 copayment fora sacroiliac joint injection provided on August 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKanjinti.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.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 has HER2 positive metastatic cholangiocarcinoma. The use of Kanjinti (trastuzumab) is not FDA-approved for the treatment of this diagnosis and is not supported by the major drug compendia. The services are not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveKanjinti
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an infusion set (A4230) and a syringe with needle (A4232) for an external insulin pump.
You asked the Plan to pre-approve the infusion set and syringe. You say that you need the requested supplies or else you will die. You say that if you are not approved, you will change your health insurance. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for coverage.
The Plan follows Medicare rules. Medicare rules say that continuous subcutaneous insulin for the treatment of diabetes mellitus when specific criteria have been met. 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 infusion set and syringe. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there was no information showing that the enrollee has a C-peptide that is less than 110% LLN of the IAb, nor is there evidence that the enrollee has had a positive antibody test suggesting autoimmunity. 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 infusion set and syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve an infusion set (A4230) and a syringe with needle (A4232) for an external insulin pump.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology visits to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says these services are
available in-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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve neurology
visits to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Intracept procedure.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are notcovered. 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 has low back pain. The Intracept procedure is considered experimental for back pain, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvean Intracept procedure