Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography.
You asked the Plan to pre-approve transthoracic echocardiography. You say that the requested transthoracic
echocardiography is medically necessary. The Plan denied your request. The Plan says that the enrollee does
not meet criteria for the requested transthoracic echocardiography.
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 transthoracic echocardiography. Our
reviewer says that the enrollee meets criteria for the requested transthoracic echocardiography. Our physician
reviewer found the enrollee is with hypertension and hyperlipidemia being treated with medical therapy for
this. He has recent telemedicine evaluation, and it was noted that he has a history of a dilated aortic root (likely
secondary to the hypertension). He has no symptoms of dyspnea or chest pain. He has been referred for
echocardiography. The enrollee has a history of hypertension and a reported dilated aortic root though no
further details are provided. However, based on the CMS LCD criteria, follow-up of an aortic abnormality
would qualify as a covered indication under the LCD for echocardiography based on both the follow up of the
systemic effects of hypertension and the abnormalities of the great vessels.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transthoracic echocardiography have been met. Therefore, we decided that the
Plan has to pre-approve transthoracic echocardiography.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is diagnosed with spinal stenosis. The Vertiflex device is experimental. More research is needed to show safety and efficacy of 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7140), local anesthesia (D9210), and suture of recent small wounds up to 5 cm (D7910 x 3).

You asked the Plan to pre-approve the dental services. You say that you do not understand why your insurance will cover dentures, but will not cover the medically necessary extractions that are required for the denture to be put in. You also say that you are in pain. The Plan denied your request. The Plan says extraction is not listed as a covered service. The Plan says that local anesthesia is not listed as a covered service. The Plan also says that suture of recent wound up to 5 cm is not listed as a covered service either.

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 an extraction (D7140), local anesthesia (D9210), and suture of recent small wounds up to 5 cm (D7910 x 3).
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 need IRF care. The Plan denied your request.
The Plan says rules for IRF care have 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that you were admitted to an acute care hospital for cardiac arrhythmia and had a
pacemaker placed. Medical 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. While you do require physical and occupational therapy, there
is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in
a different level of care. In conclusion, 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.

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 pay for the prescription drugs purchased outside of the United States from March 23, 2020, to March 31, 2020.

You asked the Plan to pay for the prescription drugs. You say that you have not been reimbursed for the enrollee's medications that you purchased. The Plan denied your request. The Plan says non-emergency drugs received outside of the United States are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that, generally, items and services provided outside of the United States (US). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prescription drugs have not been met. Additionally, the record does not indicate that these medications were provided due to an emergency. Therefore, we decided that the Plan does not have to pay for the prescription drugs purchased outside of the United States from March 23, 2020, to March 31, 2020.
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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient was admitted to an acute care hospital for sepsis and lower extremity cellulitis. Medical conditions are stable. 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 patient does 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. In conclusion, 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a negative pressure wound therapy (NPWT) pump (E2402, A6550).
You asked the Plan to pre-approve the continued coverage of a negative pressure wound therapy pump. You say that continued coverage of the wound pump is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for continued coverage, the provider must document changes in the ulcer's dimensions and characteristics on a monthly basis. 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 coverage of a negative pressure wound therapy pump. Our reviewer says that continued coverage of the wound pump is not medically necessary. Our physician reviewer found the medical records do not indicate any assessment since March. At that time, the enrollee presented to the wound center without the wound pump.
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 coverage of a negative pressure wound therapy pump have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a negative pressure wound therapy (NPWT) pump (E2402, A6550).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transportation services (A0428-ND, A0428-DN, A0425) provided on September 22, 2020.
You asked the Plan to pay for the non-emergent ambulance services. You say that the ambulance services were necessary for this enrollee, who is bedridden. The Plan denied your request. The Plan says that the destination in question is a physician's office, clinic, or an outpatient center. These are not covered destinations for ambulance transportation. In addition, transportation by van or another vehicle may have been an option.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. We found that the destination in question can qualify for coverage; however, our reviewer says that the non-emergent ambulance transportation was not medically necessary. Our physician reviewer found that the records provided do not indicate that the enrollee's clinical condition required ambulance services and that other modes of transportation were contraindicated. The rules say that ambulance services are only covered when the patient's clinical condition is such that other methods of transport cannot be used. 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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation services (A0428-ND, A0428-DN, A0425) provided on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 7, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge for teeth # 18, 19, and 20.
You asked the Plan to pre-approve the bridge. You say that tooth # 19 needs to be removed due to fracture. You say that a bridge has been diagnosed since no other teeth are missing in the lower arch. The Plan denied your request. The Plan says a bridge is not a covered benefit when a removable one can be used.
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 covers the bridge when the services are medically necessary and reasonable.
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 bridge. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found the provided documentation does not indicate that there is any reason why a removable appliance could not be worn in this situation. Therefore, the reviewer found that there would be no medical necessity for the requested 3-unit bridge. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a bridge for teeth # 18, 19, and 20.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete bilateral mastectomies.
You asked the Plan to pre-approve the complete bilateral mastectomies. You say that the requested surgical procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that Surgical treatment for gender dysphoria may be considered medically necessary when, unless medically contraindicated, there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone 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 the complete bilateral mastectomies.
Our reviewer says that coverage criteria for the requested surgical services have not been met. Our physician reviewer found the record shows the enrollee has gender dysphoria. The enrollee has not been on hormone therapy but has socially transitioned to his chosen identity. The provided records do not contain sufficient information to determine whether there is a medical rationale for not taking hormone therapy. A reference to steatohepatitis is made but documentation of this diagnosis and of a hepatology evaluation is lacking. Medicare rules require twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly, unless medically contraindicated, before surgical treatment can be considered. 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 complete bilateral mastectomies have not been met. Therefore, we decided that the Plan does not have to pre-approve complete bilateral mastectomies.
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure.
Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. The enrollee does 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.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have pre-approve 6 additional routine blood draws and 7 additional skilled
nursing visits.

You asked the Plan pre-approve the home health services. You say that the reason for the blood draw in the
home is because of the COVID restrictions. You say that the enrollee is a difficult draw. You say that the
enrollee's health is weak, she does not want to go outside, she does not have a car, and she needs a nurse to
monitor her hemoglobin. The Plan denied your request. The Plan says the enrollee is not homebound. The Plan
also says that based on the CDC guidelines the enrollee is able to resume normal activities once fully
vaccinated.

The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care
services to be 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 pre-approve 6 additional routine blood draws and 7 additional skilled nursing visits. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the enrollee does not appear to be homebound. The reviewer found that the enrollee's recent telemedicine visits appear to be an attempt to avoid exposure to Covid-19, rather than due to an inability to leave her home. The reviewer found that the enrollee does not have documented skilled nursing needs. Therefore, the reviewer found that the requested home health services are not shown to be 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 home health services have not been met. Therefore, we decided that the Plan does not have pre-approve 6 additional routine blood draws and 7 additional skilled nursing visits.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 in this case, the enrollee was admitted to an acute care hospital and underwent left colectomy due to diverticular bleed and diverticulitis. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that she is not currently receiving that would be available at the LTACH. Therefore, the elements of the coverage rules are not satisfied.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like this
denial reconsidered. The Plan denied your request. The Plan says a maximum of 10 one-way trips per year are
covered and more will be denied.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 10 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.