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

We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (33340).

You asked the Plan to pre-approve percutaneous left atrial appendage closure. You say that this is a covered and medically necessary service. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that for percutaneous left atrial appendage closure (LAAC) to be covered, the patient must have a suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation. 

We looked at the file and Medicare rules. The record shows that the enrollee is stable on long-term oral anticoagulation therapy. Based on this information, we decided that Medicare rules for coverage of percutaneous left atrial appendage closure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (33340).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on September 5, 2020.
You asked the Plan to pay for the transportation services. You say that your wife was transported to a second health facility. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the transportation services provided on September 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.

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 was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. 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. While the medical record supports a need for physical and/or occupational therapy,there is no documented need for intensive rehabilitation services. Medically necessary care 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are afraid of falling in the shower.The Plan denied your request. The Plan says this 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that this is a daily necessity for your complex care needs. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RST Sanexas treatment for the enrollee.

You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental.

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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the treatment is considered investigational as there has not been enough quality studies to support the efficacy and safety and is therefore 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve RST Sanexas treatment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the services provided to the enrollee by an out-of-network provider on October 6, 2020.
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 enrollee clearly exceeds the criteria for LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.

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 the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care, and which is the setting being offered by the Plan. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power standing system for the enrollee.

You asked the Plan to pre-approve a power standing system. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a power standing system is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approve a power standing system for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140).
You asked the Plan to pay for the limited oral evaluation - problem focused (D0140). You say that you should not be responsible for payment because you did not receive adequate service from the provider. The Plan denied your request. The Plan says this service is not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.

You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested services are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for inpatient psychiatric care have not been met.

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 care. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the enrollee was admitted to acute inpatient psychiatric hospitalization with Schizoaffective Disorder Bipolar Type and Rule out Major Neurocognitive Disorder. Based upon review the records provided, it is not expected that the enrollee would improve in a reasonable period of time beyond the dates approved for coverage by the Plan, as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was described as being calm and cooperative with no acute distress. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 14, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services should be billed under Original Medicare.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services provided on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic testing provided on November 29, 2020.

You asked the Plan to pay for molecular genetic testing. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says molecular genetic screening testing is not a
Medicare benefit for the diagnoses as listed on the claim and is done for screening purposes.

The Plan follows Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab
services in the medical record, is required for Medicare-covered laboratory services.

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 molecular genetic testing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of molecular genetic testing have not been met. Therefore, we decided that the
Plan does not have to pay for molecular genetic testing provided on November 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic (CT) angiography of the pelvis
(72191).

You asked the Plan to pre-approve CT angiography of the pelvis. You say that this service is medically
necessary. The Plan denied your request. The Plan says a second scan of the pelvis 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 CT angiography of the pelvis. Our
reviewer says that the request is not medically reasonable and necessary. Our physician reviewer found
coverage for CPT code 75635, CT angiography of the abdominal aorta with bilateral iliofemoral lower
extremity runoff was previously approved. This previously approved scan includes the pelvis. Therefore, the
requested procedure is not medically necessary and cannot be approved.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CT angiography of the pelvis have not been met. Therefore, we decided that the
Plan does not have to pre-approve computed tomographic (CT) angiography of the pelvis (72191).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis.You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you will need surgery without the inserts. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 current needs are being met at 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving gradually sufficient to likely only require additional short-term acute care services which can safely be received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when prognosis is more clear and when treatment has completed. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth 7.
You asked the Plan to pre-approve endodontic therapy. You say that you need this service. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule under your Medicare benefits. 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 endodontic therapy (D3310) for tooth 7.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.