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

We decided that the Plan does not have to pre-approveCT imaging of the chest, neck, and abdomen/pelvis.You asked the Plan to pre-approvethe CT imaging. You say that the enrollee should be allowed this imaging to monitor for recurrence.The Plan denied your request. The Plan says this imaging is not considered reasonable and necessary after five years of surveillance without new signs/symptoms of disease.The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT imaging. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found this patient is nearly 5 years from the completion of therapy. Per the NCCN guidelines, if an FDG PET/CT at 3 months post-treatment is negative, there are no data to support substantial benefit for further routine imagingin an asymptomatic patient with negative exam. In the absence of multi-institutional prospective data, a tailored approach to surveillance with attention to tumor type, stage, prognostic factors, symptomatology, and physical exam changes or restrictions is appropriate. This patient has had several negative CT scans and PET scans. A follow-up CT scan given prior scans with no evidence of disease 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 the CT imaging have not been met.Therefore, we decided that the Plan does not have to pre-approveCT imaging of the chest, neck, and abdomen/pelvis.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehab. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 9, 2020 with increasing shortness of breath and fatigue. Her oxygen requirement was resolving as of March 13, 2020. She is transitioning from seated to standing with standby assist and ambulating 100 feet with a rolling walker. Her medical conditions are stable and back at her baseline. She has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She is ambulating greater than household distances and does not require an intensive therapy program in an IRF. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 31, 2019. You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed. 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 valid physician order or clear intent to order the lab tests billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 31, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an additional $61.96 for eyeglasses provided on May 7, 2019.You asked the Plan to reimburse you for the eyeglasses. You say that you expect to be reimbursed the full amount of $300 per the Plan's eyewear benefit. The Plan denied your request. The Plan says the service is not a covered Plan benefit.The Plan follows Medicare rules. Medicare says only standard frames are covered. Medicare says the use of polycarbonate or similar material will be denied as a non-covered deluxe feature. Medicare says anti-reflective coating are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating physician. When these features are provided as a beneficiary preference item and are billed with an EY modifier and they will be denied as not reasonable and necessary. Medicare says Scratch resistant coating will be denied as non-covered.We looked at the file, Medicare's rules and the Plan's rules. The file shows that the eyeglasses you purchased were due to post cataract surgery. The eyeglasses do not fall under the Plan's routine eyewear benefit. Medicare does not cover deluxe frames, polycarbonate material and scratch resistant coating. Additionally, Medicare only covers anti-reflective coating when documented by the treating physician as medically necessary. The file does not contain documentation from the treating physician to substantiate Medicare's coverage criteria for the anti-reflective coating. Therefore, we decided that the Plan does not have to reimburse you for an additional $61.96 for eyeglasses providedon May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on October 16, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that at the time of service, an authorization was not obtained. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits. 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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on October 16, 2019 by an out of network (OON) provider.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora lipid panel provided to the enrollee on September 14, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansayscoverage criteria was not met.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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee was admitted tothe hospital following an intentional overdose. There is no indication that the enrollee had, or was thought to have, cardiovascular disease or diabetes. Basic glucose levels were normal. Lipid panels and HgbA1C levels are not part of a routine medical clearance. Therefore, the documentation does not support that the performed/billed testing was medically necessary or reasonable.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay fora lipid panel provided to the enrollee on September 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthis type of care is considered custodial.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approvelap bypass/lap hiatal hernia repair.You asked the Planto pre-approvethe repair. You say that this is medically necessary, as your GERD is so bad that the medications are not helping.The Plandenied your request. The Plansaysthatthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that services are covered 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 repair. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure gastric bypass is not for treatment of mrobid obesity but to treat post sleeve gastrectomy GERD in which case patients are unable to undergo surgical anti-reflux procedures (like LINX or laparoscopic nissen fundoplciation) given the absence of the fundus. The requested treatment will correct the complication of post sleeve GERD without significant impact on weight.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe repair have been met.Therefore, we decided that the Planhas to pre-approvelap bypass/lap hiatal hernia repair. If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe speech-language pathology services provided to the enrollee on July 17, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says the enrollee must use network providers to get care.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe speech-language pathology services provided to the enrollee on July 17, 2019 by an out of network (OON) provider.
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 a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the member is receiving appropriate inpatient
acute care and does not require transfer to the LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee is currently receiving medically necessary acute and/or critical care.
The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and
there are no issues for which the LTACH may offer a therapeutic advantage. The review has determined that
the enrollee does not require services at the LTACH that are not available at the acute care hospital where she
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical conditions have been well controlled.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, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup on tooth #13, 21, 29, and 31 (D2950).
You asked the Plan to pre-approve core buildup on tooth #13, 21, 29, and 31. You say that the service is necessary. The Plan denied your request. The Plan says the requested service is not a covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup on tooth #13, 21, 29, and 31 (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for acute-on-chronic respiratory failure. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reduce the copayment forthe total knee replacement surgery provided from November 7, 2019 to November 8, 2019.You asked the Plan to reduce the copayment forthe total knee replacement surgery. You say that the surgery was inpatient and you should only be responsible for the $200 inpatient copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $200 copayment per day for 1-5 for in-network inpatient hospital care. The Plan says you must pay a $250 copayment for the total knee replacement surgery. Based on the Plan contract, however, you cannot be asked to pay more than a $200 copayment for the total knee replacement surgery. The record shows you received a left total knee arthroplasty which is considered an inpatient surgical procedure. Therefore, we decided that the Plan has to reduce the copayment forthe total knee replacement surgery provided from November 7, 2019 to November 8, 2019.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had a prior mastectomy.
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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found it is acceptable to use daily surface imaging for breast cancer routine use, but consensus guidelines (NCCN) advocate against routine use, and billing guidelines (EviCore) explicitly state that it is not reimbursed. The case records do not describe the specific need in this 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy for the enrollee.