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

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI. You say that the enrollee is unable to receive treatment at a pain clinic due to lack of imaging. The Plan denied your request. The Plan says that the enrollee has not failed six weeks of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our physician reviewer found that the enrollee has had a history of chronic low back pain for many years. According to the medical records, he has failed conservative therapy in the past, including physical therapy. An MRI of the lumbar spine is medically reasonable for this enrollee in order to undergo full evaluation of his chronic low back pain that has not responded to conservative therapies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
If the Plan 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. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the three-dimensional (3D) rendering of an approved
magnetic resonance imaging (MRI) study of the pelvis.

You asked the Plan to pre-approve the 3D rendering of the pelvic MRI. You say that this type of imaging is
needed for planning purposes. The Plan denied your request. The Plan says this charge is not separately
payable along with the MRI.

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 3D rendering of the pelvic MRI.
Our reviewer says that the requested 3D imaging is not considered medically reasonable and necessary in this
case. Our physician reviewer found 3D rendering with interpretation and reporting of pelvic MRI with image
postprocessing is indicated when an image-guided (fusion) biopsy is planned. The medical records do not
indicate that an image-guided needle biopsy is planned. As such, there is no need for 3D imaging of the
prostate gland.

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 3D rendering of the pelvic MRI have not been met. Therefore, we decided
that the Plan does not have to pre-approve the three-dimensional (3D) rendering of an approved magnetic
resonance imaging (MRI) study of the pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Neuromuscular stimulator and supplies provided on July 30, 2020.

You asked the Plan to pay for Neuromuscular stimulator, electronic shock unit (E0745) and Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) (A4595). You say that the Neuromuscular stimulator and supplies were medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for Neuromuscular stimulator, electronic shock unit (E0745) and Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) (A4595). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested neuromuscular stimulator was medically reasonable and necessary for the enrollee in this case. A physical examination of the back would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and physical examination of the back. The supplies were not medically necessary also. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neuromuscular stimulator, electronic shock unit (E0745) and Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) (A4595) have not been met. Therefore, we decided that the Plan does not have to pay for the Neuromuscular stimulator and supplies provided on July 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on November 24, 2020.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were told you were only getting a stress test. You say that the copayment should only be $10. 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 $325 per day for Medicare-covered diagnostic radiology services. Diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan. You have been asked to pay a $325 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the myocardial perfusion imaging was performed. 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 the myocardial perfusion imaging provided on November 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional dysphagia therapy sessions.
You asked the Plan to pre-approve 10 additional dysphagia therapy sessions. You say that the 10 additional dysphagia therapy sessions are medically necessary. The Plan denied your request. The Plan says the 10 additional dysphagia therapy sessions 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 10 additional dysphagia therapy sessions. Our reviewer says that the 10 additional dysphagia therapy sessions are not medically necessary. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee and staff have been instructed on feeding guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional dysphagia therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional dysphagia therapy sessions.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a premium intraocular lens placement (S9986).

You asked the Plan to pre-approve the premium intraocular lens. You say that the premium IOL is medically
necessary. The Plan denied your request. The Plan says this type of lens is not covered under Medicare.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL.

While a premium IOL may be appropriate for you, Medicare only covers a conventional IOL. Therefore, we
decided that the Plan does not have to pre-approve a premium intraocular lens placement (S9986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (D5820) provided August 8, 2019, abutment supported retainer for porcelain fused to metal fixed partial denture (D6069) provided September 4 ,2019, and abutment supported cast metal crown (D6062) provided September 18, 2019.

You asked the Plan to pay for the interim partial denture, metal-ceramic retainer and crown. You say that the services were provided in-network and should be covered. The Plan denied your request. The Plan says the services are not included in your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the interim partial denture (D5820) provided August 8, 2019, abutment supported retainer for porcelain fused to metal fixed partial denture (D6069) provided September 4 ,2019, and abutment supported cast metal crown (D6062) provided September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are requesting retro-authorization for the out of network office visit. The Plan denied your request. The Plan says no prior authorization was 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 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 office visit provided on November 11, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a decompression procedure of the subacromial space with partial
acromioplasty.
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says that
current medical studies do not support an acromioplasty.
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 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 service. Our physician
reviewer found that you were being treated for left shoulder pain with a probable rotator cuff tear, left shoulder
impingement with type II acromion, and left shoulder proximal biceps tendinitis. You presented with aching
pain in the left shoulder that occurs constantly. Multiple surgical procedures, such as shoulder debridement,
arthroscopic capsulorrhaphy, shoulder bicep reconstruction, and distal claviculectomy have been approved.
These approved procedures have essentially the same guideline-criteria for a trial and failure of less
invasive/conservative treatments as this requested subacromial decompression. Therefore, there is inherent
evidence that reasonable and comprehensive less invasive conservative care measures have been tried and
failed to support this procedure. This included the trial and failure of medications and reduced activities, for at
least 12 weeks. There is clinical and imaging evidence of persistently painful impingement by the subacromial
process. There is compelling rationale-circumstances noted to support the medical necessity of this request as
per guidelines/literature at large. Therefore, the request for decompression of subacromial space with partial
acromioplasty is medically reasonable or 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 requested service have been met. Therefore, we decided that the Plan has to
pre-approve a decompression procedure of the subacromial space with partial acromioplasty.
If the Plan 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. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LipiFlow treatment (0207T).

You asked the Plan to pre-approve the LipiFlow treatment. You say that the treatment is medically necessary.
The Plan denied your request. The Plan says this service is investigational and is not covered.

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 LipiFlow treatment. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no evidence that this treatment would alter the outcome of cataract
surgery. There is no compelling evidence in the medical literature that the LipiFlow treatment, rather than
standard medical therapy, is required for this patient's disease.

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 LipiFlow treatment have not been met. Therefore, we decided that the Plan
does not have to pre-approve a LipiFlow treatment (0207T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided
from September 1, 2020, to September 11, 2020.

You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were told that
with skilling nursing care you had no costs unless you went past 20 days. The Plan denied your request. The
Plan says you have been asked to pay the correct cost-sharing amount.

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 $325
copayment per day, days 1-6 and a $0 copayment for additional hospital days for each in-network Medicarecovered
hospital admission/stay.

You have been asked to pay a $325 copayment for each day, days 1-6 of the inpatient rehabilitation stay. ($325
x 6 = $1,950). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record
shows you stayed at a comprehensive inpatient rehabilitation hospital. 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 the inpatient rehabilitation stay provided from September 1, 2020, to September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whole exome sequencing (WES).
You asked the Plan to pre-approve WES. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 WES. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was referred to the prescriber for evaluation of suspected pseudoxanthoma elasticum. Whole exome sequencing is being requested to determine the presence of other potential genetic disorders. The requested test is being used for screening purposes. 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 WES have not been met. Therefore, we decided that the Plan does not have to pre-approve whole exome sequencing (WES).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup procedure (D2950).
You asked the Plan to pre-approve a core buildup. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup procedure (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and gel mattress.
You asked the Plan to pre-approve a semi-electric hospital bed (E0260) and gel mattress (E0185). You say that the enrollee's caregiver lacks the physical strength to manually raise the bed. The Plan denied your request. The Plan says the documentation does not indicate that the enrollee requires frequent and immediate need for a change in body position or has pressure ulcers.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. The medical record does not support a need for frequent and immediate body position changes or that the enrollee has pressure ulcers. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed (E0260) and gel mattress (E0185) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and gel mattress.
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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on November 17, 2020.

You asked the Plan to pay for nursing facility care. You say that the treatment received was medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 nursing facility care provided by an out-of-network provider on November 17, 2020.