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

We decided that the Plan does not have to pre-approve MRI scan of lower spinal canal before and after contrast (CPT code 72158) and MRI scan of pelvis before and after contrast (CPT Code 72197).

You asked the Plan to pre-approve the MRIs. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 MRIs. Our physician reviewer found the records revealed no efforts with physical therapy (PT) or other conservative measures besides nonsteroidal anti-inflammatory drugs (NSAIDs). Also, there were no objective findings or reported symptoms suggestive of radiculopthy or a red flag diagnosis which might warrant MRI prior to trial of PT. Therefore, without sufficient support made, this request for MRI will be considered not medically necessary 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 MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI scan of lower spinal canal before and after contrast (CPT code 72158) and MRI scan of pelvis before and after contrast (CPT Code 72197).
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 these services are medically necessary. The Plan denied your request. The Plan says that your medical and rehabilitation needs are not complex and can be safely rendered 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 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. The complexity your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting. Your conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for cholecystectomy and was transferred to skilled nursing after surgery. The enrollee was discharged to home and has ongoing weakness.

The enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pennsaid 2% pump.

You asked the Plan to pre-approve Pennsaid 2% pump. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Pennsaid 2% pump does not fall under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pennsaid 2% pump.

Benefits for Pennsaid 2% pump may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic lumbar decompression.
You asked the Plan to pre-approve endoscopic lumbar decompression. The Plan denied your request. The Plan says this is an experimental procedure.
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 endoscopic lumbar decompression. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that endoscopic lumbar decompression remains experimental. More research is needed to show safety and efficacy of lumbar decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endoscopic lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic lumbar decompression.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a ride provided by your neighbor to your eye appointment on January 15, 2021.

You asked the Plan to reimburse you for a ride provided by your neighbor. The Plan denied your request. The Plan says the service or item in question is not covered under your Plan contract under any normal circumstances.

The Plan must follow Medicare rules. Medicare rules say that ambulance transportation is only covered when the supplier meets the applicable vehicle, staff, and billing and reporting requirements.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, the Medicare transportation benefit is limited to transportation by a fully equipped ambulance with appropriately trained staff. The record shows that the service at issue was not provided by a fully equipped ambulance with appropriately trained staff. This means that the service at issue is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to reimburse you for a ride provided by your neighbor to your eye appointment on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided on February 16, 2021.
You asked the Plan to pay for the limited exam. You say that both problem-focused exams were necessary and should be covered by the Plan. The Plan denied your request. The Plan says only one emergency exam to diagnose a problem may be covered per year. The Plan paid for this same exam type in January 2021, and therefore the benefit maximum has been exceeded for this 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. The Plan can cover 1 emergency diagnostic dental exam per year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the diagnostic exam is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided on February 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional OT visits.

You asked the Plan to pre-approve twelve (12) additional OT visits. The Plan denied your request. The Plan says there is no updated information that has been sent showing if the enrollee improved with therapy and if the enrollee still has things to work on with a skilled therapist. Without this information, more therapy visits cannot be approved per Medicare rules.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 twelve (12) additional OT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the documentation does not support that the unique skills of a professional therapist are required for an additional twelve (12) visits to safely and effectively provide treatment 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 twelve (12) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional OT visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the abdomen and pelvis for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the results of previous tests do not support the need for repeat tests.

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 the enrollee has signs and symptoms suspicious for inflammatory bowel disease. The GI specialist stated a desire to obtain a CT enterography in order to evaluate for possible Crohn's disease. However, nowhere in the notes or orders is there mention of an MRI. MRI enterography is also a test used for evaluation of the bowel lumen and could be used as a diagnostic tool in this case but no such order is present. In summary, a cross sectional enterography exam is clinically reasonable but a correct order must be entered in order to establish medical necessity.

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 MRI of the abdomen and pelvis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the required prescription and evaluations have not been completed.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation is not clear that you are unable to use a walker or a manual wheelchair. While you may have the cognitive ability to safely operate a power wheelchair, the documentation does not support that the requested wheelchair can safely be maneuvered in the home. There is no documentation that your home is accessible for the device.

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 12, 2020, to October 14, 2020.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that inpatient admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 12, 2020, to October 14, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot insert (CPT code L3000).
You asked the Plan to pre-approve the foot insert. You say that you need the foot insert because you cannot walk and if you do not have the foot insert it will affect your diabetes and your heart problem. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan states the requested orthotics are independent of a diabetic benefit. The Plan states the diabetic benefit related orthotics have different CPT codes and have different criteria for coverage. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot insert (CPT code L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the hyperbaric oxygen therapy you received from November 6, 2019, to November 27, 2019.

You asked the Plan to waive the co-payment. The Plan denied your request. The Plan says you are responsible for the cost share.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 co-payment for each surgical or observation room service you get at an outpatient hospital.

Review of the file shows that you had 16 hyperbaric oxygen therapy treatments from November 6, 2019, to November 27, 2019. You have been asked to pay a $275 co-payment for each treatment, totaling $4,400. The services fall within the outpatient hospital 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 co-payment for the hyperbaric oxygen therapy you received from November 6, 2019, to November 27, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the reduce the copayment for a medical eye exam provided on November 23, 2020.

You asked the Plan to waive the reduce the copayment for a medical eye exam. You say that you should only owe a $10 copayment, not a $15 copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $10 co-payment for each eye exam to treat a disease or condition of the eye for vision care.

The medical records show that you received a medical eye exam on November 23, 2020. Therefore, you cannot be asked to pay more than a $10 co-payment.

The Plan says you must pay a $15 co-payment for a medical eye exam. Based on the Plan contract, however, you cannot be asked to pay more than a $10 co-payment for each eye exam to treat a disease or condition of the eye. Therefore, we decided that the Plan has to waive the reduce the co-payment for a medical eye exam provided on November 23, 2020 from $15 to $10.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee protector.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that items and services that do not have a medical purpose 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 item. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested knee protectors are not medically necessary per Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1 as the requested items do not primarily serve a medical purpose.

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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee protector.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthesis with a new prosthetic foot and ankle system for the enrollee.

You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says a request for a complete prosthesis with a K3 foot does not meet the Medicare criteria as being reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that special prostheses are covered based on functional status.

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 prosthesis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the enrollee utilizes a cane which is not consistent with K3 level ambulation. The criteria have not been 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 the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthesis with a new prosthetic foot and ankle system for the enrollee.