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

We decided that the Plan does not have to pre-approvean auricular percutaneous electrical nerve stimulator.You asked the Plan to pre-approveauricular nerve stimulator. You say that you would be an excellent candidate for this and would likely obtain significant therapeutic benefit from it.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this device is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of auricular nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvean auricular percutaneous electrical nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.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 enrollee has a history of back pain. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wheelchair ramp.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the item is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea wheelchair ramp
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network radiation oncologist.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network radiation oncologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveContour blood glucose test strips.You asked the Plan to pre-approveContour blood glucose test strips. You say that you have been using this brand for many years.The Plan denied your request. The Plan says this is not a Plan-preferred brand. The Plan has also indicated that your provider has ordered you a Plan-preferred glucose meter.The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.
We looked at the file and Medicare rules.The record does not indicate that there is a medical reason you cannot use the Plan's preferred brands.Based on this information, we decided that Medicare rules for coverage of Contour blood glucose test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveContour blood glucose test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea therapeutic continuous glucose monitor.You asked the Plan to providea therapeutic continuous glucose monitor. You say that the enrollee has necrotic fingertips and cannot check on fingertips.The Plan denied your request. The Plan says they failed to receive additional information supporting the criteria.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe abutment and abutment-supported crown rendered on November 19, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.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 abutment and abutment-supported crown rendered on November 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis and an abscess of the right shoulder. His medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided September 3, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that this service was medically necessary.The Plan denied your request. The Plan says the proof of delivery did not corroborate the delivery ticket submitted.The Plan must follow Medicare rules. The rules state thatDMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. Specifically, a purported proof of delivery was provided without a signature. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided September 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechemical neurolysis of the medial branch nerves.You asked the Plan to pre-approvechemical neurolysis of the medial branch nerves. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that chemical neurolysis of the medial branch nerves are only covered for certain indications.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 chemical neurolysis of the medial branch nerves. Our reviewer says that the documentation doesnot support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee Thoracic Spondylopathy. The enrollee had lumbar scoliosis corrected. The enrollee has a spinal cord stimulator in place. The enrollee is taking oxycodone, Flexeril, Nucynta and nonsteroidal anti-inflammatory drugs for pain. The enrollee had diagnostic thoracic facet blocks and had excellent and sustained relief, but the pain has returned. Chemical neurolysis of the thoracic medial branchnerves is no evidence-based therapy and radiofrequency ablation, both pulsed and regular radiofrequency ablation are contra-indicated in the proximity of a spinal cord stimulator. Therefore, the enrollee does not meet criteria for the requested 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 chemical neurolysis of the medial branch nerves have not been met.Therefore, we decided that the Plan does not have to pre-approvechemical neurolysis of the medial branch nerves.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea left heart catheterization.You asked the Plan to pre-approvecatheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458). You say that there is a strong recommendation for proceeding with a left heart catheterization.The Plan denied your request. The Plan says criteria is not met for this procedure.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the patient has increased coronary risk (increased coronary calcium), chest pain that is not characterized in the records provided and a recent normal nuclear stress test. In this setting the uncharacterized chest pain and a normal nuclear stress test coverage criterion for coronary angiography is not met. Current guidelines endorsed by several national organizations also do not consider coronary angiography appropriate in this 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 catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458) have not been met.Therefore, we decided that the Plan does not have to pre-approvea left heart catheterization
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the chest.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted imaging reports show the enrollee has stable lung nodules. There is no evidence of significant changes and there is no support for repeat imaging at thistime. The requested chest CT 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the chest.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services (G0483 and 80307) provided on July 15, 2020.You asked the Plan to pay forthe drug testing services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.We looked at the file and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the drug testing services have not been met. Specifically, this claim was billed with a laboratory place of service code, but the record indicates that the face-to-face service was rendered in an office setting.Therefore,we decided that the Plan does not have to pay forthe drug testing services (G0483 and 80307) provided on July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) care beyond March 4, 2021.You asked the Plan to pre-approvecontinued SNF care. You say that you cannot return home.The Plan denied your request. The Plan says you no longer need skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted medical records do not show that you have any identifiable skilled nursing or therapy service needs. You do 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 continued SNF care have not been met.Therefore, we decided that the Plan does not have topre-approvecontinued skilled nursing facility (SNF) care beyond March 4, 2021.
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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepsychiatric services to be provided by an out-of-network provider.Youasked the Plan to pre-approvepsychiatric services. You say that any disruption in services would be a detriment to your health and wellbeing. You say that continuing to see the doctor is in your best interests.The Plan denied your request. The Plan says care must be received by a network provider.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 psychiatric diagnostic evaluation and psychotherapy. Our reviewer says that the enrollee does not require treatment by an out-of-network provider as the Plan is able to provide a psychotherapist for the treatment. Our physician reviewer found there is no documentation of treatment failure or the inability of this enrollee to attend treatment from an in-network psychologist.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approvepsychiatric services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout-of-network office visits.You asked the Plan to pre-approveout-of-network office visits. You say that you are requesting a different physician due to dissatisfaction with a plan provider.The Plan denied your request. The Plan says out-of-network services are excluded from coverage.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-approveout-of-network office visits
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ankle x-ray provided on October 23, 2020.You asked the Plan to waive the copayment forthe ankle x-ray. You say that you received a letter saying all copayments for 2020 were going to be paid.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for basic radiological services at an in-network specialist's office or freestanding radiological facility. You have been asked to pay $33.42, which is less than the standard $50 copayment for the ankle x-ray. The ankle x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan says that only copayments for primary careservices, outpatient behavioral health visits and telehealth visitsare beingpaid.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 forthe ankle x-ray provided on October 23, 2020.