Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/6/20 diagnosed with gastrointestinal (GI) bleed/melena, post hemorrhagic anemia, gastritis, and diverticulitis. The records indicate the member has chronic kidney (end-stage) disease on hemodialysis and heart failure. The member has coronary artery disease (CAD) and has undergone coronary artery bypass graft (CABG) in the past. Now, the enrollee has stable hemodynamics and is non-toxic/afebrile. The enrollee is supervised for bed mobility, but minimal/moderate assist for activities of daily living and transfers. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound/dialysis care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living and 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health services to be provided by out of network provider.You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare rules say that plans can require enrollees to get care from network providers. The requested provider in this case is not a network provider with the Plan. Although you have a point-of-service benefit for certain covered services, out-of-network home health agency care is not a covered benefit. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approvethe home health services to be provided by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole body PET with CT scan (78816).
You asked the Plan to pre-approve a whole body PET with CT scan (78816). You say that the requested whole
body PET with CT scan is medically necessary. The Plan denied your request. The Plan says the requested
whole body PET with CT scan is not medically necessary.
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 a whole body PET with CT scan
(78816). Our reviewer says that the requested whole body PET with CT scan is not medically necessary. Our
physician reviewer found the enrollee is with hypoglycemia. The request is for a PET CT scan to rule out
occult malignancy. Based on the documentation provided, and Medicare criteria, the request is not medically
necessary as cancer is not strongly suspected. A PET CT scan is not used as a screening test for 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 a whole body PET with CT scan (78816) have not been met. Therefore, we
decided that the Plan does not have to pre-approve a whole body PET with CT scan (78816).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care services.You asked the Plan to pre-approveadult day care services. You say that the member needs these services due to cognitive impairment.The Plan denied your request. The Plan says Medicare does not cover custodial services.The Plan must follow Medicare rules. The rules say that custodial care is not covered.We looked at the file and Medicare rules. The requested adult day care is custodial in nature and not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of adult day care services have not been met.Therefore, we decided that the Plan does not have to pre-approveadult day care services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).You asked the Plan to pre-approveProcrit (J0885). You say that the requested Procrit is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail the preferred drug, Retacrit first.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 Procrit (J0885). Our reviewer says that the plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with chronic kidney disease and anemia. Procrit injection has been requested. The provided medical records do not indicate that the enrollee has tried and failed the required drug, Retacrit first. The provided medical records do not indicate that the Plan's requireddrug would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit (J0885) have not been met.Therefore, we decided that the Plan does not have to pre-approveProcrit (J0885)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 3, 2019.You asked the Plan to pay fortheorthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on March 14, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on March 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered to the enrollee by "the provider" on August 1, 2019 to August 31, 2019.You asked the Plan to pay forthese 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered to the enrollee by "the provider" on August 1, 2019 to August 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee by "the provider" on July 10, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered to the enrollee by "the provider" on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on December 19, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99239 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 forthe hospital discharge services rendered on December 19, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cyclobenzaprine 10mg tablet.You asked the Plan to pre-approve this medication. You say that the patient is unable to take the preferred medications due to having Chronic Kidney disease.The Plan denied your request. The Plan says the member has a medical (MA) only policy with the plan, not a Prescription Drug Plan (PDP).  Therefore, drug coverage is limited to Medicare Part B drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Cyclobenzaprine 10mg tablet.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided on August 13, 2019.
You asked the Plan to pay for the nursing facility visit. You say that the services are medically necessary. You say that the claim should be paid whether there is authorization or not. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 nursing facility visit provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99205, 99215) to be provided by the out of
network provider.
You asked the Plan to pre-approve office visits. You say that you are appealing the denial of this claim. The
Plan denied your request. The Plan says out of network care is provided only when there is an urgent or
emergent illness or injury. The Plan says there is no indication in the medical records that the member has an
urgent or emergent medical condition as it would be stated in the documentation. The Plan also says that there
are physicians in the UFIP network that are able to provide these services.
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 pre-approved care.
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
office visits (99205, 99215) to be provided by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Coflex IntelaminarSpinous process stabilization device.You asked the Plan to pre-approvethe Coflex Intelaminar Spinous process stabilization device. You say that the requested device is not a fusion device. You say that, with the requested device, there is less tissue dissection, less blood loss, and the device is surgically fitted for the defect once the decompression of the stenosis has been completed by the surgeon. You say that the alternative surgery would involve a decompressive laminectomy with medial facetectomy and foraminotomy and one level arthrodesis.The Plan denied your request. The Plan says the records show the enrollee to have low back pain and some narrowing of the nerve canal areas. The plan says that the available medical evidence is not quality enough to show if the procedure is safe and helpful.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 Coflex Intelaminar Spinous process stabilization device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device being requested is considered experimental and more research is needed. The records do not show that there is instability.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 Coflex Intelaminar Spinous process stabilization device have not been met.Therefore, we decidedthat the Plan does not have to pre-approvethe Coflex Intelaminar Spinous process stabilization device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent transportation taxi services.You asked the Plan to pre-approvenon-emergent transportation taxi services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says non-emergent transportation taxi services are not covered by Medicare and you do not have a supplemental transportation benefit with the Plan.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of non-emergent transportation taxi services have not been met.Therefore, we decided that the Plan does not have to pre-approve non-emergent transportation taxi services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 14, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for caries risk assessment and documentation, with a finding of moderate risk (D0602), and the bitewings (D0273) provided on October 8, 2019.You asked the Plan to pay forthe dental services. You say that you sat down with the office and was advised the service would be covered. You also say that you were advised by the Plan that you could see this provider.The Plan denied your request. The Plan says the dental services are not listed as covered services.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forcaries risk assessment and documentation, with a finding of moderate risk (D0602), and the bitewings (D0273) provided on October 8, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee would benefit from additional
rehabilitation in a SNF. The Plan denied your request. The Plan says the enrollee is unable to make therapy
improvements due to underlying conditions.
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 necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, had clear lungs, and tolerated a regular diet. The enrollee received physical
and occupational therapy in the SNF. The enrollee was at minimal to contact guard assist level with functional
mobility, including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of
daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy
service needs. The enrollee does not meet the 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 skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the claims should be paid because it was an emergency situation. You say that you were in a diabetic coma and you were really out of it while making the transportation decision. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 15, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.