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

We decided that the Plan does not have to pre-approve an MRI of the arm joint.
You asked the Plan to pre-approve the MRI. 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 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found you were being treated for calcific tendinitis of right shoulder. You presented with complaints of right shoulder pain that you noted had been ongoing for years, with recent increased swelling and pain. The pain was noted to be unbearable and associated with difficulty with arm raising up and out. Exam revealed tenderness of the shoulder, along with limited range of motion. However, previous imaging including x-ray and ultrasound corroborated the working diagnosis of calcific tendinitis. Detailed documentation is not evident regarding the requested physical therapy (on 1/4/21) having been completed with no benefit. Therefore, the requested MRI of the right shoulder without contrast is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the arm joint.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on October 20, 2020.
You asked the Plan to pay for the services. You say that this was an emergent case which required air transport. The Plan denied your request. The Plan says the enrollee was inappropriately transported by air ambulance to a more distant facility.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.
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 services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation did not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the patient's health. We looked at this physician's review, the file, and Medicare rules. Our doctor found that the documentation did not support the need for air ambulance services. Additionally, the enrollee was not transported to the nearest appropriate facility. 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 air ambulance services provided to the enrollee on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular interim partial denture (D5821) provided on
October 27, 2020.
You asked the Plan to pay for the mandibular interim partial denture. You say that you would like this service
to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your
dental plan.
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
mandibular interim partial denture (D5821) provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (C2624).
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee will benefit greatly from the requested procedure and implant. The Plan denied your request. The Plan says the requested treatment is experimental/investigational.
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 a CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS implantable pulmonary artery pressure monitoring device is medically reasonable and necessary for the enrollee in this case. 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device (C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hysterectomy and cystoscopy.
You asked the Plan to pre-approve a total hysterectomy and cystoscopy. You say that the requested total hysterectomy and cystoscopy are medically necessary. The Plan denied your request. The Plan says the requested total hysterectomy and cystoscopy are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a total hysterectomy and cystoscopy. Our reviewer says that the requested total hysterectomy and cystoscopy are not medically necessary. Our physician reviewer found the enrollee is with Pelvic and perineal pain. On 1/21/21 it is noted that "pain persists". The enrollee is on metoprolol, omeprazole, and gabapentin. There is no physical exam recorded. An ultrasound performed on 1/19/21 revealed multiple fibroids in the uterus, an enlarged right ovary with an adjacent cyst, a simple cyst in the left ovary, a simple cyst superior to the uterus, and a large mass extending to the right and left sides in the cul-de-sac. An MRI performed on 2/11/21 demonstrated suprapubic and pelvic masses most compatible with multifocal endometriosis and fundal intramural uterine fibroids. An atypical ovarian neoplasm was not excluded. Medical therapy is typically tried before surgery. The documentation is insufficient to demonstrate that a total hysterectomy and cystoscopy are medically reasonable and necessary for the enrollee in this case, 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 hysterectomy and cystoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a total hysterectomy and cystoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on September 8, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the records provided do not support the billed item in this case.
The Plan follows Medicare rules. Medicare rules say that records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and 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 pay for this item. Our reviewer says that the medical records do not support the billed item in this case. Our physician reviewer found that there is no documentation that the lumbar sacral orthosis provided in this case is medically reasonable and necessary as the records do not show a face to face (or telehealth) examination of the enrollee by the prescribing provider.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on September 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the left knee.

You asked the Plan to pre-approve an MRI of the left knee. You say that the requested MRI of the left knee is medically necessary. The Plan denied your request. The Plan says the requested MRI of the left knee 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 left knee. Our reviewer says that the requested MRI of the left knee is not medically necessary. Our physician reviewer found in this case; the enrollee was being treated for left knee pain. Enrollee notes 6-month history of left knee pain that has progressed. One month ago, he noticed medial sided left knee pain that has resulted in considerable amount of decrease in his tolerance to weight-bearing activities. Exam reveals full motion with mild discomfort of endpoints. There is no evidence of crepitus or instability. There is moderate tenderness to palpation along the medial joint, positive McMurray's and reproducible pain over the medial joint. X-rays demonstrate well-preserved joint space, with early symptoms of patellofemoral osteoarthritis, no acute fractures, or other acute abnormal findings. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive conservative care measures. Advanced imaging is not supported without failure of conservative measures (without mechanical symptoms being demonstrated.) Therefore, the requested MRI of the left knee is not medically reasonable or necessary for the enrollee in this case.

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 left knee have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI of the left knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation with dental codes D9222 and D9223, and therapeutic drug injection with dental code D9612.
You asked the Plan to pre-approve dental codes D9222, D9223 and D9612. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D9222, D9223 and D9612 are not covered under the Plan's supplemental dental benefit.
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, dental codes D9222, D9223 and D9612 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep sedation with dental codes D9222 and D9223, and therapeutic drug injection with dental code D9612.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on 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 admission to a SNF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum assisted suspension system (VASS). You asked the Plan to pre-approve a vacuum assisted suspension system (VASS). You say that the requested vacuum assisted suspension system (VASS) is medically necessary. The Plan denied your request. The Plan says the requested vacuum assisted suspension system (VASS) 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 a vacuum assisted suspension system (VASS). Our reviewer says that the requested vacuum assisted suspension system (VASS) is not medically necessary. Our physician reviewer found the vacuum assisted suspension system (VASS) is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The physician's objective documentation does not support the need for this suspension system. The findings of the residual limb on the exam do not indicate a need for this socket over a standard socket. There is no evidence of volume fluctuation, skin issue or other finding on the physician exam that indicates the need for this system. 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 vacuum assisted suspension system (VASS) have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum assisted suspension system (VASS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 27, 2020. You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 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 a domiciliary, rest home visit provided on July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an
IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 you do not require the intensity of services provided at an IRF. Specifically, you
are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician
evaluation. Your care needs can be met at a lower 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on May 15, 2020.
You asked the Plan to pay for the initial nursing facility care. The Plan denied your request. The Plan says the services were provided without the appropriate prior authorization and the services were not urgent/emergent.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for initial nursing facility care provided on May 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 24,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges
because this was a telehealth visit. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for specialist visits.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve additional IMRT with IGRT fractions.
You asked the Plan to pre-approve additional IMRT with IGRT fractions. You say that the requested additional IMRT with IGRT fractions are medically necessary. The Plan denied your request. The Plan says that the requested additional IMRT with IGRT fractions are 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 additional IMRT with IGRT fractions. Our reviewer says that the requested additional IMRT with IGRT fractions are medically necessary. Our physician reviewer found for this case; the issue is the appropriateness of 44 fractions vs. moderate hypofractionation. Treatment with more fractions is costlier, which is the root of the dispute. However, 44 fractions in considered acceptable (albeit not preferable) by NCCN guidelines and ASTRO, ASCO, and AUA Evidence-Based Guideline - with the expert guidelines acknowledging some limitations in the data. As such, the standard medical necessity criteria are met as the treatment with 44 fractions of IMRT would be "furnished in accordance with accepted standards of medical practice". The LCD only addresses the need for IMRT, and not the need for additional number of fractions. Therefore, the decision is based on standard medical necessity. The request is therefore favorable (for 16 additional fractions in addition to the 28 already approved). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional IMRT with IGRT fractions have been met. Therefore, we decided that the Plan has to pre-approve additional IMRT with IGRT fractions.
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.