Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedestruction of intraosseous basivertebral nerve.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysin order for the requested services to be covered, there must be medical records documenting pathology response to this modality.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/investigational procedure at this point. Therefore, the request is considered 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 forcoverage of the procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvedestruction of intraosseous basivertebral nerve.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomographic angiography of the neck for the enrollee.You asked thePlan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show results of a picture study using sound waves of the blood vessels of the neck.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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found based on the records, the enrollee has a history of carotid dissection but no recent focal neurologic deficits and no evidence of arterial vascular insufficiency by anklebrachial indices or other testing. In addition, there are no documented recent vascular ultrasound images with reported abnormalities. In this circumstance the documentation does not support the medical necessity for CT angiography.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomographic angiography of the neck for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not require frequent rehab physician management, or an interdisciplinary approach for rehab 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 above.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 physician reviewer found that the enrollee was admitted to the acute hospital for pneumonia and anemia. His medical problems are stable. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.The medical record supports a need for physical and occupational therapy,but it does not support a need for an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEpidural Steroid Injections (62321).You asked the Plan to pre-approvethe injections. You say that the injections are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records are from July 2018. Without more recent medical records the service is not supported.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 injections have not been met.Therefore, we decided that the Plan does not have to pre-approveEpidural Steroid Injections (62321).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveinpatient psychiatric hospital services for the enrollee.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that that the member could have been cared for in outpatient care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are medically reasonable and necessary for the enrollee in this case. This enrollee does appear to require inpatient mental health treatment as although she was not a danger to herself or others and was cooperative with care without any aggressive behaviors, this patient was unable to care for herself. It does appear that active treatment is taking place. It does appear that the services are reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's condition meets criteria for coverage of inpatient psychiatric 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 inpatient psychiatric hospital services have been met.Therefore, we decided that the Plan has to pre-approveinpatient psychiatric hospital services for the enrollee.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/orsend 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hetlioz, 20 mg capsule.
You asked the Plan to pre-approve Hetlioz. You say that the requested drug should be covered. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hetlioz, 20 mg capsule.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe anesthesia services provided on January 11, 2020.You asked the Plan to pay forthe services. The Plan denied your request. ThePlan says that the services were not billed with a valid provider type.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that the services were billed with the incorrect provider type.However, CRNAs are allowed to provide anesthesia, and the correct modifier was billed to show that the anesthesia services were provided by a CRNA with the medical direction of a physician. The Plan has not provided a rule to show why the provider type isincorrect in this case. Without this documentation, the Plan's denial cannot be substantiated.Therefore, we decided that the Plan has to pay forthe anesthesia services provided on January 11, 2020.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 toopen the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable, and no longer requires an acute level of care.
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 requires weaning of high flow oxygen, oral medications, respiratory therapy, frequent labs and doctors' visits and therapy, all of which can be safely done in the current acute care setting. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/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. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora duplex scan provided to the enrollee on June 8, 2020.You asked the Planto pay forthe scan. You say that this should be paidfor.The Plandenied your request. The Plansayspayment will be considered whenever a corrected claim is provided.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 93970 is "Duplex scan of extremity veins including responses to compression and other maneuvers."We find that CPT code 93970 is not supported in the medical record. Specifically, the diagnosis code billed is not appropriate. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available. Based on this information, we decided that Medicare rules for coverage of the scan have not been met.Therefore, we decided that the Plandoes not haveto pay fora duplex scan provided to the enrollee on June 8, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visit for assistance with activities of daily living
and personal care (99509).
You asked the Plan to pre-approve home visit for assistance with activities of daily living and personal care.
You say that you need the extra help. The Plan denied your request. The Plan says the service or item in
question is not covered under the member's contract under any normal circumstances.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 home visit for assistance with activities of daily living and personal care have
not been met. Therefore, we decided that the Plan does not have to pre-approve home visit for assistance with
activities of daily living and personal care (99509).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of chronic
low back and left leg pain. Current evidence based medical guideline and peer reviewed literature do not fully
support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a
lack of large volume, long-term peer-reviewed outcome studies to support the use of the Superion spacer for
this enrollee's medical condition. The services are experimental in nature and 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveInjectafer.You asked the Plan to pre-approveInjectafer. You say that the requested Injectafer is medically necessary.The Plan denied your request. The Plan says that the requested Injectafer is 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 Injectafer. Our reviewer says that the requested Injectafer is medically necessary. Our physician reviewer found patients with gastric bypass are known to have poor oral iron absorption and are prone to iron deficiency anemia. This enrollee took oral iron with no significant increase in her iron stores. She is symptomatic with mild anemia. The use of IV iron is reasonable and 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 Injectafer have been met.Therefore, we decided that the Plan has to pre-approveInjectafer.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of home health care.You asked the Plan to pre-approvethe continuation of home health care. You say that the requested continuation of home health care is medically necessary.The Plan denied your request. The Plan says the requested continuation of home health care is not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 continuation of home health care. Our reviewer says that the requested continuation of home health care is not medically necessary. Our physician reviewer found in this case, the documentation doesn't support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services inorder to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.She has been discharged from all skilled services from 12/10/2020.  The documentation supports that she is at or near her baseline level of function and health.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 continuation of home health care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of home health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repair and reconditioning of hearing aids.You asked the Plan to pre-approve repair and reconditioning of hearing aids. You say that you got water damage to your hearing aids and you do not want topay for new hearing aids. The Plan denied your request. The Plan says hearing aids repairs are not covered by Medicare and not covered by the Plan.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefitthat exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the fileand the Plan's rules. The file shows that that Plan covers hearing aids with a $750 allowance for up to two hearing aids per year. Thereis no coverage under the Plan's hearing aid benefit for repairs and reconditioning of hearing aids. Therefore, we decided that the Plan does not have to pre-approve repair and reconditioning of hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.
You asked the Plan to pre-approve a bath/shower chair. 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 a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe cost share charged for acupuncture services provided on August 3, 2020.You asked the Plan to waivethis cost share. You say that these services should be covered at no charge.The Plan denied your request. The Plan says they have partially overturned the decision and reimbursed an additional $3.48 minus the $15 copayment applied for acupuncture services received. The Plan is upholding the $15 copayment applied to service.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 $15 copayment for acupuncture services. 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 waivethe cost share charged for acupuncture services provided on August 3, 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 enrollee meets the criteria for coverage of IRF. You say that the enrollee will benefit from care in an IRF that cannot be accomplished at a lower level of care. You say that the records provided support the medical necessity of care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 was admitted for treatment of aortic stenosis. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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.