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

We decided that the Plan does not have to pre-approve a total hip replacement.

You asked the Plan to pre-approve a total hip replacement. 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 follows Medicare rules. Medicare rules say that Medicare will consider Total Hip Arthroplasty (THA) medically reasonable and necessary when specific indications are 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 a total hip replacement. Our reviewer says that the services are not medically necessary. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Detailed documentation is also not evident regarding abnormalities such as malignancy of the joint, avascular necrosis, fracture, non-union or failure of previous hip surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for right total hip arthroplasty does not meet the coverage criteria detailed in the LCD. 

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 total hip replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a total hip replacement.
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 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 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 medically necessary. Our physician reviewer found you were admitted to the hospital and had an above-knee amputation. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 28, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one
CPT code must be submitted for the panel. There was no specific clinical rationale for the requested lab studies. The review has determined that the laboratory services provided to the enrollee on August 28, 2020 were not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 28, 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 LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the
current acute setting. The LTACH would provide no additional services. With additional time in the current
setting, clinical stability can be ensured, and the appropriate lower level of care can be determined. Criteria for
admission to an LTACH have not been met.

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 acute hospital care, and acute care services have not been
denied. Long term acute care hospitals are certified as acute care hospitals, and in general do not provide
clinical services that are materially different than those of short-term acute care hospitals. 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 they are currently receiving care.

The documentation also does not support that an additional 25 days of hospitalization are reasonably expected
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on January 7, 2021, by a supplier not enrolled in the Medicare program.

You asked the Plan to pay for an oxygen concentrator. You say that the item at issue was a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue is not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on January 7, 2021, by a supplier not enrolled in the Medicare program.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with severe rhabdomyolysis, acute kidney failure requiring dialysis, sepsis, cellulitis, metabolic encephalopathy, and atrial fibrillation. He has n complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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.
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 IRF is a better facility and would provide more effective care. The Plan denied your request. The Plan says you require physical and occupational therapy as well as pain control with oral medicine and management of medications you take daily. You do not need to be seen by a rehab doctor at least 3 times a week for evaluation of functional and medical goals, and you do not need an intensive team for your care. You can safely receive the services you require in other settings, such as a skilled nursing facility.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that at this point you should be able to complete the
necessary hours of physical therapy required for an acute rehab setting. Your providers say that intense
physical therapy in an acute setting is required for you to have a full recovery. The Plan denied your request.
The Plan says the documentation does not indicate that you have comorbidities that would require close
supervision by a rehabilitation physician, nor is there documentation that there is a need for a required intensive
and coordinated interdisciplinary approach to providing rehabilitation.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183).
You asked the Plan to pre-approve an MRI of the abdomen. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested MRI will not change the enrollee's treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the abdomen. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found a short (6-month) interval follow-up by requested MRI is medically appropriate in the setting of unequivocally and persistently dilated pancreatic duct given member's history of breast malignancy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the abdomen have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for medical nutrition therapy provided on April 6, 2021.

You asked the Plan to waive the copayment for medical nutrition therapy. You say that the Plan gave you a list of providers and you were under the impression that you would not owe anything. 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 there are no cost-sharing charges for in-network medical nutritional therapy and a $50 copayment for out-of-network medical nutrition therapy when provided by a specialist. 

The record shows that you received medical nutritional therapy from an out-of-network provider on April 6, 2021. Therefore, you are responsible to pay the $50 copayment.

You have been asked to pay a $50 copayment for out-of-network medical nutrition therapy. Medical nutrition therapy falls within the medical nutrition therapy 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 medical nutrition therapy provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve superficial radiation therapy (SRT) services.

You asked the Plan to pre-approve the SRT services. You say that the medical records provided support the need for the requested services. The Plan denied your request. The Plan says superficial radiation of the skin is meant for recurrence and hard to treat skin cancers. The Plan says that superficial radiation is not medically necessary in this case.

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 SRT services. Our reviewer says that superficial radiation therapy services are not considered medically reasonable and necessary in this case. Our physician reviewer found lack of demonstration of need for SRT versus traditional external beam radiation. Our physician reviewer found that statements from the National Comprehensive Cancer Network (NCCN) guidelines and medical societies question the use of SRT. It would therefore not be considered to be furnished in accordance with accepted standards 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 SRT services have not been met. Therefore, we decided that the Plan does not have to pre-approve superficial radiation therapy (SRT) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial consultation for a cytoscopy, possible bladder biopsy, possible turp and transrectal ultrasound with biopsy of the prostate to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the out-of-network services. You say that you would like reconsideration because this procedure is urgent and was requested by your specialist. The Plan denied your request. The Plan says the provider is out-of-network and the requested service may be provided by participating providers.

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 an initial consultation for a cytoscopy, possible bladder biopsy, possible turp and transrectal ultrasound with biopsy of the prostate to be provided by an out of network (OON) provider.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 patient does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an immediate upper denture (D5130), and an immediate lower denture (D5140) provided on December 12, 2020.

You asked the Plan to pay for an immediate upper denture, and an immediate lower denture. You say that you do not understand why the services are not covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 an immediate upper denture (D5130), and an immediate lower denture (D5140) provided on December 12, 2020.