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

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay 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 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 medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approveacute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe occlusal guard (D9944) provided on July 6, 2020.You asked the Plan to pay forthe occlusal guard. You say that you would like an exception made, and for the guard to be covered.The Plan denied your request. The Plan says this service is not covered by the 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 forthe occlusal guard (D9944) provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on May 20, 2020.
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services rendered. You state you made a mistake in sending the receipt for two pairs of glasses and the second one was for reading glasses. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. You had previously submitted a reimbursement request to the Plan's supplemental vision vendor, on June 12, 2020, in the amount of $189.98. That claim was paid by the vendor on June 18, 2020. Your EOC states, routine vision hardware- One purchase of routine vision hardware; eyeglasses lenses and frame, and disposable or conventional contact lenses, every two (2) calendar years. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of network
provider on July 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was
not obtained.
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 services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided on May 22, 2020.
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for DME provided on May 22, 2020.
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 an LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute careand 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 patient is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and sepsis in the setting of advanced cancer. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from the ventilator to a tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the samelevel of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs

.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecervical radiofrequency ablation onboth sides of the neck (64633, 64634).You asked the Plan to pre-approvecervical radiofrequency ablation. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the request isnot medically necessary because the records do not document the necessary degree of improvement in the enrollee's pain to justify radiofrequency ablation.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 cervical radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the documentation indicates that the enrollee had MBBs x 2 bilateral C2-C5 on 8/28/20 which reportedly provided > 80% pain relief.  However, there was no subjective or objective statement cited supporting the degree of relief the enrollee experienced with either of these injections. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approvecervical radiofrequency ablation on both sides of the neck (64633, 64634)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick.
You asked the Plan to pre-approve Repatha SureClick. You say that the enrollee is not able to use statin
therapy. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by
Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Repatha SureClick.
Benefits for Repatha SureClick 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary. The Plan denied your
request. The Plan says that there was insufficient evidence to support the use of Rituxan in this clinical
situation.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Rituxan. Our reviewer says that
Rituxan is not medically reasonable and necessary for the enrollee in this case. Rituxan is not FDA approved
for secondary immune neutropenia. The drug is not supported in any of the CMS compendia for the requested
use. You submitted an abstract from 2005 which is a report of two cases. CMS does not recognize abstracts or
case reports to determine medically accepted use. The conclusion was that further randomized studies will
define the role of the drug in autoimmune diseases. A PubMed search found no articles to support the requested
use. The requested use of Rituxan is not listed as not indicated, not supported or not recommended for this use
in any of the CMS compendia. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for Rituxan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Rituxan for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic (CT) angiography, neck, (70498).
You asked the Plan to pre-approve the CT scan. You say that you want to be approved for the neck scan to get
a better understanding of what type of issues he is dealing with. The Plan denied your request. The Plan says
the request for computed tomography angiography is not medically necessary.
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 scan. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this case the member had previously undergone MRA of the head which revealed a possible
abnormality at the tip of the basilar artery. CTA of the bran was recommended (and this study was approved by
the member's health plan). CTA of the neck was also ordered. However, the imaging study that was already
approved for the member (CTA brain) would readily cover the anatomical region in question/of concern. The
member is not noted to have any other findings which would localize to the vasculature evaluated exclusively
by a CTA of the neck. Therefore, there would not be a need to perform an additional CTA scan, that is in
addition to the one already authorized.
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 scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve computed tomographic (CT) angiography, neck, (70498).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device (a device to monitor for heart failure) (CPT Codes 33289 and C2624).
You asked the Plan to pre-approve the CardioMEMS device. 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 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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered experimental or investigational. 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device (a device to monitor for heart failure) (CPT Codes 33289 and C2624).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continued stay in a skilled nursing facility (SNF) after November 27, 2020.You asked the Plan to pre-approvethe continued stay in a SNF. You say that you need SNF care.The Plan denied your request. The Plan says rules for SNF care have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF whenthe 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 continued stay in a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Furthermore,  the beneficiary does not require skilled nursing or therapy services on a daily basis and 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 continued stay in a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continued stay in a skilled nursing facility (SNF) after November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist services. You say that your provider will not refer you out-of-network.The Plan denied your request. The Plan says there are in-network providers available for 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 care that cannot be provided by network providers.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-approvespecialist services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided on April 13, 2020, to April 22, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for a sleep study. You say that you were referring by your primary care physician. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is also out-of-network. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a sleep study provided on April 13, 2020, to April 
22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings (D0274) provided on June 26, 2020.You asked the Plan to pay forthe bitewings. You say that prior to the appointment, you contacted the Plan looking for an in-network provider, and were told the services would be covered. You also say that the provider should have been aware of the type of x-ray your insurance covers.ThePlan denied your request. The Plan says this service is not covered by the 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 forthe bitewings (D0274) provided on June 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora computed tomography (CT) scan of the thorax (71250) provided on August 4, 2020.You asked the Plan to pay fora CT scan of the thorax. You say that this procedure is supported by the records.The Plan denied your request. The Plan says this service was not billed with the necessary modifier. We decided that the Plan does not have to pay fora computed tomography (CT) scan of the thorax (71250) provided on August 4, 2020.You asked the Plan to pay fora CT scan of the thorax. You say that this procedure is supported by the records.The Plan denied your request. The Plan says this service was not billed with the necessary modifier.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctlyandthat physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71250has a Column One/Column Tworelationship with code 71275, which was billed by a physician with the same specialty and group practice for the same date of service,and cannot be paid as billed. This code cannot be paid without a modifier to indicate it was a separate service. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay fora computed tomography (CT) scan of the thorax (71250) provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care to begin on December 2, 2020.You asked the Plan to pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatientmental health care. Our physician reviewer found based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 2, 2020, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as you have been receiving long-acting injectable medication.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care to begin on December 2, 2020.