Persius/hicric huggingface dataset:
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 inpatient rehabilitation so you can walk. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services could be safely received in another setting.
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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical repair of a hip fracture after a fall. Medical problems 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 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 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 microprocessor foot.
You asked the Plan to pre-approve these 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 requested item exceeds your medical need. The documentation does not reveal supporting physician medical progress notes indicating you are at a K3 level and have a need for the requested microprocessor foot. Additionally, the requested foot has Bluetooth capability and a sandal toe foot shell design that are not primarily medical in nature. 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 a K3 microprocessor foot.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT code 70553), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says guidelines support MRI Brain without and with contrast for follow-up imaging after diagnosis of high grade gliomas or grade III meningiomas every three months for three (3) years, then every six (6) months thereafter. The Plan states the clinical information provided does not describe this imaging timeframe and, therefore, the request is not indicated at this time.

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 the MRI. Our physician reviewer found guidelines support MRI Brain without and with contrast for follow-up imaging after diagnosis of high grade gliomas or grade III meningiomas every three months for three (3) years, then every six (6) months thereafter. The last MRI brain from May 19, 2021, was stable and without new changes to warrant closer follow-up than 6 months. This request for repeat MRI is prior to the 6-month mark and would be considered premature based on the enrollee's stable pattern. Therefore, this request for MRI will be considered not 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT code 70553), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy you had on January 18, 2021.

You asked the Plan to pay for the colonoscopy. The Plan denied your request. The Plan says the benefit limit has been exceeded.

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 $0 copayment for one screening colonoscopy every 24 months. 

Review of the file shows that you had a screening colonoscopy on January 18, 2021. The records also show that you had a covered screening colonoscopy on July 9, 2020. Therefore, the requested procedure is the second in a 24-month period, which exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the colonoscopy you had on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

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 indicates that the enrollee does not use insulin with at least three daily injections and does not require 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 pre-approve a therapeutic continuous glucose monitor.
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 have had bad experiences with other
rehabilitation providers and need this specific rehab. The Plan denied your request. The Plan says the denial of
authorization for IRF service is correct.
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 the complexity of your nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, lower extremity; without contrast material (CPT code 73700) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says there are in-network providers that can provide the service.
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-approve
CT, lower extremity; without contrast material (CPT code 73700) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve peripheral nerve stimulator and supplies (CPT code K1018 and K1019), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that medical studies have not proven that the service(s) or procedure(s) is helpful for treatment of the enrollee's health problem.
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 services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found a neurologist had no further treatment options for the enrollee and the Cala Trio is an effective alternative to medication with less side effects according to the limited evidence available, making it reasonable and medically necessary for this enrollee. 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 services have been met. Therefore, we decided that the Plan has to pre-approve peripheral nerve stimulator and supplies (CPT code K1018 and K1019), for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxervate Sol 20 mcg/ml.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage.

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 Oxervate Sol 20 mcg/ml.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extensive oral evaluation (D0161) provided November 18, 2020.

You asked the Plan to pay for the extensive oral exam. You say that the services should be covered. The Plan denied your request. The Plan says your claims have been reprocessed, however, the extensive oral exam is not a covered service.

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 extensive oral evaluation (D0161) provided November 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299 x 4).

You asked the Plan to pre-approve the home health services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the enrollee does not require skilled services.

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 home health services. Our reviewer says that the skilled services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. Therefore, the reviewer found that the requested home health services are not currently 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 to pre-approve skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraspinal chiropractic manipulation (98943) and mechanical traction therapy (97012).

You asked the Plan to pre-approve extraspinal chiropractic manipulation and mechanical traction therapy. You say that you need this to alleviate your pain. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan also covers routine visits.

The records show that the services at issue are not manual manipulation of the spine or routine visits. Therefore, we decided that the Plan does not have to pre-approve extraspinal chiropractic manipulation (98943) and mechanical traction therapy (97012).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve the additional trips. You say that the enrollee has multiple scheduled visits for medical needs. You say that the enrollee requires transportation to allow him to maintain his visits throughout the year. You also say that the 24 one-way trips are not adequate for the enrollee to maintain his health. The Plan denied your request. The Plan says the benefit allows for up to 24 one-way trips per calendar year. The Plan says that trip 25 and beyond are not a covered benefit. The Plan also says that the frequency limit has been exhausted.

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 24 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray and does not have to waive the
coinsurance for Medicare Part B drugs provided on February 23, 2021.

You asked the Plan to waive the copayment for an X-ray and to waive the coinsurance for Medicare Part B
drugs. You say that you paid the $30 copayment and should not be responsible for the additional charges. The
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct 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 $30 copayment for X-rays. Your contract with the
Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs.

You received an X-ray on February 23, 2021. Therefore, you are responsible to pay the $30 copayment.
You received Medicare Part B drugs on February 23, 2021. The total allowed amount is $14.52 and 20% of
that is $2.90.

The total amount you owe is: $32.90.

You have been asked to pay the total amount of $32.90 for an X-ray and Medicare Part B drugs. An X-ray falls
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B
drugs fall within the Medicare Part B prescription drugs benefit category. 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 an X-ray and does not have to waive the coinsurance for Medicare Part B drugs provided on
February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you do understand this denial. The Plan denied
your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 6, 2021, by an OON provider.

You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 had network providers available who could have provided 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 an office visit provided on January 6, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home oxygen.

You asked the Plan to pre-approve home oxygen. You say that you have COPD and been on oxygen since 2013. The Plan denied your request. The Plan says you do not meet criteria for the requested oxygen.

The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 

We looked at the file and Medicare rules. Review of the file shows that no medical records were submitted for review for this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this information, we decided that Medicare rules for coverage of home oxygen have not been met. Therefore, we decided that the Plan does not have to pre-approve home oxygen.