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

We decided that the Plan does not have to pre-approve neck spine surgery (cervical decompression and fusion).
You asked the Plan to pre-approve these 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have no documented neurological deficits on exam. You have no documented spinal instability that meets the criteria for fusion surgery. The x-rays do not show significant abnormal motion. The requested surgery is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve neck spine surgery (cervical decompression and fusion).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and supplies for the enrollee.You asked the Plan to pre-approve a Dexcom continuous glucose monitor and supplies. You say that it is medically necessary for the enrollee to monitor his blood glucose.The Plan denied your request. The Plan says that there is no reason for a non-formulary product.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.Theitems at issue are a Dexcom continuous glucose monitor and supplies. Dexcom is not a preferred provider with the Plan for diabetic supplies. Abbott and Ascensisa are the preferred providers.Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and supplies for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergent ambulance services provided on December 20, 2019.
You asked the Plan to waive the copayment for non-emergent ambulance services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received non-emergent ambulance services on December 20, 2019. You Are asked to pay a $50 copayment for the ambulance services. 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 non-emergent ambulance services provided on December 20, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvearthroscopic shoulder surgery with distal clavicle excision, subacromial decompression, and possible rotator cuff repair.You asked the Plan to pre-approvethe shoulder surgery. You say that the enrollee would benefit from this surgery to reduce pain and increase range of motion.The Plan denied your request. The Plan says that there is not sufficient evidence thatsurgical intervention is warranted at this time.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the shoulder surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with persistent and occasionally sharp anterior left shoulder pain with painful loss of motion. Functional limitations are noted in activities of daily living. Clinical exam findings documented rotator cuff atrophy and positive impingement and rotator cuff provocative testing. There is radiographic evidence of impingement morphology and acromioclavicular joint osteoarthritis. He had failed reasonable and/or comprehensive conservative treatment. Surgery has been recommended to include acromioplasty and distal clavicle excision with planned arthroscopic evaluation of the rotator cuff and treatment as indicated. Evidence based medical literature would support the medical necessity of acromioplasty/subacromial decompression and distal clavicle excision at this time based on clinical exam, radiographic findings, and failure of conservative treatment. Rotator cuff repair may be reasonably indicated at the time of surgery based on operative findings, considering thephysical exam findings of rotator cuff atrophy and positive provocative testing. MRI is not necessary in the pre-operative period given the clinical indications for shoulder surgery are already met. Therefore, the request for shoulder surgery, including subacromial decompression, distal clavicle excision, and possible rotator cuff repair, would be considered medically reasonable and 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 shoulder surgery have been met.Therefore, we decided that the Plan has to pre-approvearthroscopic shoulder surgery with distal clavicle excision, subacromial decompression, and possible rotator cuff repair.If thePlan 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. Thisdoes not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nascobal spray for the enrollee.You asked the Plan to pre-approve this drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered under Part B.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 Nascobal spray for the enrollee.Benefits for this drug 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 a Gel-One injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied for not meeting step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary.
Our physician reviewer found the review has determined that you have not tried and failed the plan's required drug(s). There is no documentation indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for you. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
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 continued acute hospital stay was offered, until the enrollee can discharge to
a lower level of care.
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 short-term acute care hospital can provide for all the enrollee's present inpatient
care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the
short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such
as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora gym membership purchased on January 20, 2020.You asked the Plan to pay fora gym membership. You say that you were informed that you would get reimbursed for the gym membership.The Plan denied your request. The Plan says they confirmed that there are gyms that participate in their Plan within 20 miles of your address. The Plan states that you purchased a membership at this facility and they are not a part of the Plan's network.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the gym membership at this facility is not eligible for reimbursement as they do not participate in the Plan's Fitness program. Your EOC states, there are no out-of-network facilities available for this benefit.Therefore, we decided that the Plan does not have to pay fora gym membership purchased on January 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled services of a registered nurse (G0162), pump analysis (62370), ziconotide injection (J2278) and hydromorphone injection (J1170) provided on August 29, 2019.You asked the Plan to pay forthe registered nurse services, pump analysis and drugs. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says providers and suppliers are subject to consolidated billing and must be aware that separate Medicare payment will not be made to them. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. Additionally, the direct supervision requirement must still be met with respect to every non-physician service.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for the registered nurse services, pump analysis and drugs have not been met. Specifically, the record indicates that these services were rendered by a resident nurse. There is no evidence in the record that the physician directly supervised these services.Therefore, we decided that the Plan does not have to pay forskilled services of a registered nurse (G0162), pump analysis (62370), ziconotide injection (J2278) and hydromorphone injection (J1170) provided on August 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 6, 2019 by an out of network provider.You asked the Plan to pay for the onabotulinumtoxina injection (J0585)and chemodenervation of muscle (64615). You say that the injections were medically necessary.The Plan denied your request. The Plan says prior authorization was not requested.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 the medical services provided on November 6, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on January 23, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says this code should be reported for preoperative
evaluations only, but an additional diagnosis for the condition to describe the reason for the surgery is required.
The Plan must follow Medicare rules. Medicare rules say that for patients receiving preoperative evaluations
only, sequence first a code from subcategory Z01.81 and then assign a code for the condition to describe the
reason for the surgery as an additional diagnosis.
We asked our coder 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 chest x-ray. Our reviewer says that it is not appropriate to
bill diagnosis code Z01.818 on its own for the service rendered. Our reviewer found another diagnosis code is
required to support the medical necessity of the surgery.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not
have to pay for a chest x-ray (71046) provided on January 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve weekly skilled nursing (SN) visits to be provided in the home health setting.You asked the Plan to pre-approve the weekly home health services. You say that the enrollee requires weekly care from a skilled nurse in order to monitor his condition, especially due to the recent ER visit.The Plan denied your request. The Plan says the enrollee has no ongoing complex skilled nursing needs.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 weekly home health services. Our reviewer says that the documentation does not support that further home health services are medically necessary for this enrollee. Our physician reviewer found the patient has been receiving home health services since April 2020 and recently was sent to the ED due to chest pain, tachycardia, hypotension. Ongoing skilled nurse visits are requested. Skilled services are not required to treat the patient's illness or injury, improve the patient's condition, maintain the patient's condition, or prevent deterioration of the patient's condition The patient has had prior extensive SN services. He had no evidence of ongoing SN need such as complex wound care or new enteral feeding. He has had education on his medical conditions and management. Additional SN visits are not 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 weekly home health services have not been met.Therefore, we decided that the Plan does not have to pre-approve weekly skilled nursing (SN) visits to be provided in the home health setting.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SmartPill Wireless Motility Capsule (WMC) procedure.You asked the Plan to pre-approvethe requested procedure. You say that the WMC procedure is ideal for assessment of the full GI tract to better understand the underlying cause of the symptoms.The Plan denied your request. The Plan says there is no clinical information documenting medical necessity.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 requested procedure. Our physician reviewer found that the Wireless Motility Capsule (SmartPill, WMC) is FDA approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalized dysmotility. However, WMC has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers, and is not more readily available than gastric motility or colon transit testing. As such, while WMC is FDA-approved, more conventional motility studies that meet health plan coverage criteria should be considered. Therefore, the requested procedure is not considered 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 requested procedure have not been met. Therefore, we decided that the Plan does not have to pre-approvea SmartPill Wireless Motility Capsule(WMC) procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.
You asked the Plan to pre-approve Humira (J0135). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B for the enrollee's condition.
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 Humira.
Benefits for Humira (J0135) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly standby assist for functional transfers and activities of dailyliving (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on February 25, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Sufficient information was not provided from the provider as evidenced by prescription is out of date (May 25, 2017) and last Oximetry Testing was done in 2008. A more current MD order would be required as well as current oximetry testing results. The doctor refuses to sign new prescription. Therefore, we decided that the Plan does not have to pay for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on February 25, 2020.