Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Magnetic Resonance Angiogram (MRA).
You asked the Plan to pre-approve an MRA. You say that the requested MRA of the neck is medically
necessary. The Plan denied your request. The Plan says that the requested MRA of the neck is not medically
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 an MRA. Our reviewer says that the
requested MRA of the neck is medically necessary. Our physician reviewer found in this case the member is
noted to have a history of bilateral Supraclinoid internal carotid artery (ICA) aneurysms. Given the anatomical
location of said aneurysms, they would best be visualized by the performance of MRA of the neck. Based on
the results of the requested imaging study there may be a basis on which surgical intervention is deemed to be
necessary in the more immediate future (versus a need for further surveillance imaging). In that regard
performance of MRA of the neck would meet the NCD requirements for coverage and would otherwise be
reasonable and 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 an MRA have been met. Therefore, we decided that the Plan has to pre-approve
a Magnetic Resonance Angiogram (MRA). 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: 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 on May 12, 2021 and received physical and occupational therapy. The physical therapy note dated May 27, 2021 states you need assistance with sitting and standing up and walking six feet. The records do not support that you need the intensity of services provided at an IRF.
Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
November 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 by an out-of-network provider on
November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be provided in a lower level of care setting, such as with home health services.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. The enrollee does 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthyretin amyloidosis (TTR) testing.
You asked the Plan to pre-approve TTR testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because without definitive diagnosis of amyloidosis affecting the heart, genetic testing brings no additional useful information and is therefore not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that transthyretin amyloidosis (TTR) testing is not covered at this time. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTR testing have not been met. Therefore, we decided that the Plan does not have to pre-approve transthyretin amyloidosis (TTR) testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the Vertiflex device 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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom sensor.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the sensor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there is no clinical rationale for the requested monitor. The documentation indicates that the enrollee only checks her blood glucose one time daily. The enrollee has not been using insulin multiple times (3 or more) a day. The treatment does not require frequent adjustment on the basis of testing results. 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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 11, 2021.
You asked the Plan to waive the copayment for urgent care visit. You say that this provider did not examine your issue, so should not be paid by the Plan or your copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $30 copayment for urgent care visit. You have been asked to pay $30 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3348) provided on
November 18, 2020.
You asked the Plan to pay for the dental service. You say that 2 different dentists advised you have a root
canal. You say that you do not know why a problem developed years after your initial root canal. You also say
that you were just following the advice of the 2 qualified dentists. The Plan denied your request. The Plan says
retreatment of a previous root canal is not listed as a covered 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 pay for the
retreatment of a previous root canal (D3348) provided on November 18, 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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member does not require transfer the a LTACH.
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 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fMRI.
You asked the Plan to pre-approve the fMRI. You say that you would like reconsideration because this MRI is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Functional MRI of Brain in the setting of metastatic renal cell cancer to the lung has not been demonstrated in the peer-reviewed literature.
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 the Functional MRI. Our reviewer says that fMRI is not generally considered to be reasonable and necessary as an initial stating study for cancer. Rather, such testing has no diagnostic value or yield in the stating or evaluation of metastatic conditions. Our physician reviewer found its clinical utility is largely limited to some perioperative settings which are not otherwise applicable to the case at hand. In that regard the requested service cannot be determined to be reasonable and necessary for the member 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 Functional MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the fMRI.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on September 29, 2020.
You asked the Plan to pay for the surgical services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 surgical services provided on September 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on October 1, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not cover services rendered to beneficiaries in custody. 

We looked at the file and Medicare rules. The file shows that the enrollee was in custody for the date of service at issue. 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 pay for the physician services rendered on October 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (64636, 64635).
You asked the Plan to pre-approve facet joint radiofrequency ablation. You say that you are in excruciating pain and want to return to normal life. The Plan denied your request. The Plan says you have not had a second MBB.
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction (RFA) of facet joint nerves is considered medically reasonable and necessary for patients who have had at least two diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain. 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 facet joint radiofrequency ablation. Our reviewer says that the criteria for coverage of radiofrequency ablation has not been met. Our physician reviewer found the records show that you have had only one set of diagnostic MBBs which was "positive." No percentage of pain relief is documented. A second MBB is required before the requested procedure can be covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (64636, 64635).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on November 23, 2020.
You asked the Plan to waive the copayment for these services. You say that the provider told you that the visit would incur the same copayment as a PCP visit. The Plan denied your request. The Plan says the copayment was applied correctly.
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 $35 copayment for each in-network Medicare-covered visit with a specialist.
Review of the file shows that you received specialist services on November 23, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the in-network Medicare-covered visit with a specialist 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. The Plan cannot be held responsible for possible misinformation regarding your cost sharing given by a provider. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 8 fillings, the crown, and the core build up provided from September 11, 2020, to September 23, 2020.
You asked the Plan to pay for the fillings, crown, and core build up. You say that you were told by your doctors that the dental work had to be done as medical coverage before any chemotherapy or radiation could be done. You say that your chemo and radiation were put on hold until the dental work was completed. You say that it was your understanding that these services had to be done as part of the medical procedures and should be covered. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that routine dental services are not covered by Medicare.
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. The Plan covers dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the fillings, crown, and core build up are not medically necessary. Our physician reviewer found the services that were rendered do not rise to the level of non-routine dental care as the teeth would be treated whether or not the medical condition of the tongue was to be treated. Therefore, the reviewer found that services do not meet the Plan criteria for coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fillings, crown, and core build up have not been met. Additionally, the services you are asking the Plan to pay for 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 pay for the 8 fillings, the crown, and the core build up provided from September 11, 2020, to September 23, 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 IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for uremic pericarditis and end stage renal disease. 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. There is no documented need for intensive rehabilitation services. 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. Medicare coverage criteria are not met. 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.