Persius/hicric huggingface dataset:
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 needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on September 13, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the shoulder. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dynasplint right hand orthosis, bilateral elbow extension and right wrist extension.
You asked the Plan to pre-approve a right hand orthosis, bilateral elbow extension and right wrist extension. You say that because of a medical condition the enrollee needs the Dynasplint right hand orthosis, bilateral elbow extension and right wrist extension The Plan denied your request. The Plan says there are no clinicals documenting surgery, or joint deformities or contractures.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a right hand orthosis, bilateral elbow extension and right wrist extension have not been met. Therefore, we decided that the Plan does not have to pre-approve Dynasplint right hand orthosis, bilateral elbow extension and right wrist extension.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 asymptomatic premature menopause and age-related osteoporosis. The records show that she has not tried and failed the plan's required drug of zoledronic acid. The required drug would not be less effective or contraindicated; therefore, Prolia is not reasonable or 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 Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the
enrollee on May 30, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says they were unable to discover any evidence of an established
relationship between the member and the ordering physician. The Plan states there were no claims submitted
for an evaluation and management service. The Plan states the review of claims history for this member, and a
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service
with the ordering physician as required per CMS guidelines.
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 orthosis. Our reviewer says that the
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the
case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for
the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately
assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not
support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is
insufficient documentation of a credible physical examination of the shoulder.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on May 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another 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. Our
physician reviewer found the enrollee is currently undergoing treatment at an ACH, having apparently been
admitted in early January 2020. The enrollee is receiving tube feeds via a nasogastric tube, but these are being
decreased as the enrollee is taking in more oral nutrition on her own. The enrollee is participating in
rehabilitative services. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide
the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can
remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the pelvis (72195).
You asked the Plan to pre-approve an MRI of the pelvis (72195). You say that the requested MRI of the pelvis
is medically necessary. The Plan denied your request. The Plan says the requested MRI of the pelvis is not
medically necessary.
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 pelvis (72195). Our
reviewer says that the requested MRI of the pelvis is not medically necessary. Our physician reviewer found
the enrollee has a granulosa-theca cell tumor. CT scans from 11/2019 show a mass in pelvis. Based on the
documentation provided, the enrollee is not a candidate for chemo and is on letrozole. As CT scans already
show a mass, the requested MRI of the pelvis is not reasonable and necessary. Consideration for biopsy or PET
CT can be entertained. The requested MRI will add no new information.
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 pelvis (72195) have not been met. Therefore, we decided that the
Plan does not have to pre-approve an MRI of the pelvis (72195).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc Injections (J7325).
You asked the Plan to pre-approve the Synvisc injection. You say that the Synvisc injection is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Viscosupplementation of joints other than the
knee are not covered.
We looked at the file and Medicare rules. The request is for viscosupplementation of a joint other than the
knee. Based on this information, we decided that Medicare rules for coverage of the Synvisc injection have not
been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc Injections (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971) and wrist hand orthosis (L3916) provided to the enrollee on August 21, 2019.You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested ankle/foot orthosis was medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankle and foot would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the ankle and foot. The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist 
would reasonably be required to adequately assess whether the wrist/hand orthoses were medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wrist.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay forankle foot orthosis (L1971) and wrist hand orthosis (L3916) provided to the enrollee on August 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for SNF services.
You asked the Plan to pre-approve the SNF services. You say that you believe the enrollee will benefit from short-term rehabilitation. The Plan denied your request. The Plan says does not meet Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at a stand by assist to contact guard assist level with functional mobility including gait to 300 feet. He required varying assist with activities of daily living. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on
a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for SNF services.
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 would be best for this patient.The Plan denied your request. The Plan says it is not possible for an LTACH to offer any clinical benefit over remaining in the current facility indefinitely.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 patient is currently undergoing treatment at an ACH for hypernatremia and dehydration, following a recent stroke resulting in the placement of a tracheotomy and feeding tube. The enrollee is not currently on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift recliner.You asked the Plan to pre-approve the seat lift mechanism of a seat lift recliner.You say that your current chair is wobbly and you have fallen from it.The Plan denied your request. The Plan says your physical therapy evaluation does not note difficulty standing from a seated position.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.Medicare does not cover the upholstered portion of a seat lift chair.We looked at the file and Medicare rules. The record shows the physical therapist does not recommend a seat lift recliner. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift reclinerhave not been met. Therefore, we decided that the Plan does not have to pre-approvea seat lift recliner.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the iFuse SI joint fusion.You asked the Plan to pre-approvethe surgery. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of this health problem.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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of Si joint instability, fracture, or tumor. Si joint fusion for degnerative back pain remains experimental. More research is needed.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvethe iFuse SI joint fusion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 13, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan will not pay any claims submitted by you.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgently needed service provided on September 22, 2019.
You asked the Plan to waive the copayment for the urgently needed service. You say that you do not consider a nurse practitioner a specialist and should not have to pay a specialist copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $25 copayment for urgently needed services at an in-network urgent care center. You have been asked to pay a $25 copayment for the urgently needed service. The urgently needed service falls within the "Urgently needed services" benefit category. The record shows you received the service at an immediate care center.
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 the urgently needed service provided on September 22, 2019.