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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission.

You asked the Plan to pay for the SNF services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee is not shown to have a daily skilled nursing need or skilled therapy need. The Plan says that a safer environment and appropriate care can be provided at a lower level than inpatient SNF.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there are no complex rehab needs that can only be met in the IRF.

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 were admitted for right leg numbness and weakness. Medical problems 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. 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 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an aorta duplex for the enrollee.

You asked the Plan to pre-approve the duplex. You say that this is medically necessary. The Plan denied your request. The Plan says that a repeat study before a three year interval is not reasonable or necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 duplex. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee is a high risk for aneursymal progression given the co-morbid medical conditions. The previous measurement is 3.9. The requested test is medically reasonable and necessary given the clinical scenario and history of vascular disease. The requested test is recommended.

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 duplex have been met. Therefore, we decided that the Plan has to pre-approve an aorta duplex 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/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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 30.

You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary. The Plan denied your request. The Plan says core build up is a dental service. The Plan also says that core build up is not listed as a covered dental service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement headgear (A7035) for a BiPAP device more often that every six months.

You asked the Plan to pre-approve the headgear. You say that this is medically necessary. The Plan denied your request. The Plan says replacement headgear can be approved at a rate of one every six months.

The Plan must follow Medicare rules. Medicare rules say that A7035 is covered once every six months. 

This quantity and rate of supply is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the headgear have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement headgear (A7035) for a BiPAP device more often that every six months.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for strapping provided on May 21, 2020.
You asked the Plan to waive the copayment for strapping. You say that you had the same service done during
previous visits and only paid a $15 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 $125
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
The medical records show that you received strapping at an outpatient hospital facility on May 21, 2020.
Strapping is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $125
copayment.
You have been asked to pay a $125 copayment for strapping. Strapping falls within the outpatient surgery and
other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 strapping provided on May 21, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) myocardial imaging (78429).
You asked the Plan to pre-approve PET myocardial imaging. You say that you cannot do a regular stress test.
The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET myocardial imaging. Our reviewer
says that the criteria for coverage of the requested PET scan have been met. Our physician reviewer found the
records show that you have an appropriate indication for stress testing based on an intermediate to high pre-test
probability of coronary artery disease (obesity, hyperlipidemia, diabetes) with concomitant symptoms
consistent with exertional ischemia (chest pain and shortness of breath). Based on age and body habitus, you
cannot exercise well for a reasonable workload EKG exercise test. You require a pharmacologic imaging study
and PET has been ordered. CMS rules state that PET myocardial perfusion scanning, when clinically
appropriate, can be used in place of SPECT imaging as long as SPECT is not being performed as well. As this
is the case in this instance, the pharmacologic PET myocardial study meets CMS criteria for use and is
clinically appropriate and medically necessary as well.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PET myocardial imaging have been met. Therefore, we decided that the Plan
has to pre-approve positron emission tomography (PET) myocardial imaging (78429).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for knee surgery.

You asked the Plan to pre-approve inpatient admission. The Plan denied your request. The Plan says inpatient admission is 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 inpatient admission. Our reviewer says that the requested inpatient admission is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is undergoing a planned elective left knee surgery. The enrollee is medically stable with a past medical history only significant for osteoarthritis. The planned procedure, listed under CPT code 27447, is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no specific clinical rationale for the requested inpatient admission. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for knee surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional supplemental benefits, including routine
transportation, allowance for healthy food purchases and/or bill payments, and home assistance services.
You asked the Plan to pre-approve these services. You say that the Plan denied your request. The Plan says you
do not meet the criteria for coverage.
Medicare does not cover transport in a vehicle that is not an ambulance, healthy food purchases, bill payments,
or home assistance services. However, the Plan offers a supplemental benefit that covers these services. The
Plan covers these services for people with specific chronic illnesses.
We looked at the file and the Plan's rules. The file shows that you do not have a chronic illness for which the
Plan covers special supplemental benefits. Based on this information, we decided that the Plan's rules for these
services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional
supplemental benefits, including routine transportation, allowance for healthy food purchases and/or bill
payments, and home assistance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the lumbar spine without contrast.
You asked the Plan to pre-approve CT scan. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this CT scan is correct, because the enrollee's condition could be assessed through different means such as X-Ray or conservative therapy.
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 scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found there is no clinical rationale for the requested test. There is no documentation that testing of the enrollee's reflexes or muscle strength to potentially locate the cause of the enrollee's symptoms. There is no documentation that the enrollee had tried any provider-directed conservative therapy. The enrollee's medication list had no pain medications or anti-inflammatories listed. There is no documentation that the enrollee has had an X-Ray of her lumbar region. The requested CT scan is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the lumbar spine without contrast.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the compliance criteria was not 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found during the trial of auto-CPAP, you were unable to meet minimum Medicare usage criteria of at least 4 hrs/day for at least 70% of days. The usage has been 9% of days. There has been no subsequent clinical visit to address compliance issues. Continued CPAP is considered not medically necessary because usage is insufficient for clinical benefit. 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 continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 11, 2020, to January 14, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that inpatient care was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 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 the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 11, 2020, to January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided by an out-of-network provider on September 21, 2020.
You asked the Plan to pay for the annual wellness visit. You say that the treatment was medically necessary. You say that payment should be made despite the absence of authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided by an out-of-network provider on September 21, 2020.
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 lumbar spinal stenosis. The requested Superion spacer remains experimental in nature, as more research is needed to show its safety and efficacy. Open laminectomy surgery remains the gold standard procedure for spinal stenosis. The Superion spacer 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network provider.

You asked the Plan to pre-approve cataract surgery. You say that you want to appeal the denial. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inlyta 5mg tablet for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is intended for patient self-administration.

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 Inlyta 5mg tablet for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional miles for routine transportation services.

You asked the Plan to pre-approve the additional miles. You say that you would like reconsideration because your specialists are more than 30 miles away. The Plan denied your request. The Plan says you have coverage for up to 30-mile limit applies per trip.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 30 miles per trip. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional miles for routine transportation services.