Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus IBD sgi Diagnostic test provided on June 2, 2020.

You asked the Plan to pay for the Prometheus IBD sgi Diagnostic test. You say that the test was ordered by the enrollee's physician so the Plan should pay this claim. The Plan denied your request. The Plan says this test is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the Prometheus IBD sgi Diagnostic test have not been met. Therefore, we decided that the Plan does not have to pay for the Prometheus IBD sgi Diagnostic test provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee received only about 50% relief temporarily from cervical interlaminar epidural injections with steroids in the past.
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 injections. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has cervicalgia. The pain is moderated in nature and located primarily axial. The pain has been present for more than three months and has failed noninvasive conservative therapy. The record does not indicate a untreated radicular component. The record does not indicate non-facet pathology. The record does not indicate more than four diagnostic facet joint injections in a rolling twelve month period. The elements of the coverage rule are 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 injections have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) repeat RFA (CPT code 64636 and 64635) for the enrollee.
You asked the Plan to pre-approve the repeat RFA. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 repeat RFA. Our physician reviewer found as per Medicare guidelines, a maximum of two (2) levels is covered at one time for patients. 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 repeat RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) repeat RFA (CPT code 64636 and 64635) for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arformoterol Tartrate.
You asked the Plan to pre-approve Arformoterol Tartrate. You say that the enrollee is at risk for pneumonia. The Plan denied your request. The Plan says the enrollee has not tried and failed Perforomist.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Arformoterol Tartrate. Our physician reviewer found that the enrollee has a history of chronic obstructive pulmonary disease. The Plan requires a trial of Perforomist before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective or likely have adverse effects for the 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 Arformoterol Tartrate have not been met. Therefore, we decided that the Plan does not have to pre-approve Arformoterol Tartrate.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine trips. 
 
You asked the Plan to pre-approve additional trips. You say that your routine trip benefit is going to be used up 
soon. You say that you need more rides. You also say that you have future doctor appointments along with 
physical and occupational therapy that you will need rides to. The Plan denied your request. The Plan says to 
the pharmacy or specialist appointments). The Plan also says that once the benefit has been exhausted, there are 
no additional rides available to non-primary care physician locations for the duration of the calendar year. 
 
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 36 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 additional routine trips are not covered once you have exhausted the Plan maximum benefit. Therefore, we 
decided that the Plan does not have to pre-approve additional routine trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of a full upper denture.
You asked the Plan to pre-approve replacement of a full upper denture. You say that the requested services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 dental care procedures that meet the criteria determined by the Plan. 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 replacement of a full upper denture. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation supports the reline and repair of the current denture.
A new denture does not meet the criterion of once every five years.
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 replacement of a full upper denture have not been met. Therefore, we decided
that the Plan does not have to pre-approve replacement of a full upper denture.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for heart surgery. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While he may benefit from further therapy, he does not require an intensive therapy program in an IRF. There is not a reasonable expectation that the enrollee 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 pay for the critical care services coded 99291 provided on January 30, 2021.
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on January 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881).

You asked the Plan to pre-approve Aranesp. You say that the requested drug is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been
met because the enrollee has not tried and failed the treatment alternative Retacrit.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the
requested treatment is not medically necessary. Our physician reviewer found that, based on the medical
records provided, the enrollee has not tried and failed the Plan's required drug. There is no indication in the
medical records provided that the Plan's required drug would likely be less effective and/or likely have adverse
effects for the 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 Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on January 21, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes".

We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 30-74 minutes of critical care services were provided on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on February 26, 2021.
You asked the Plan to waive the copayment for laboratory tests. You say that you pay $200 a month and feel that the Plan should cover these 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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory tests provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) (93702).
You asked the Plan to pre-approve BIS. You say that this is a covered service. The Plan denied your request. The Plan says that this is experimental.
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 BIS. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. Bioimpedance spectroscopy is used for diagnosis as well as assessing treatment response. Bioimpedance spectroscopy (BIS) is an increasingly utilized diagnostic technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard of care. This patient has bilateral breast cancer, and her risk of lymphedema is in both arms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BIS have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) (93702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compounded gabapentin powder, ketoprofen powder, and lidocaine bulk crystal.
You asked the Plan to pre-approve the compounded gabapentin powder, ketoprofen powder, and lidocaine bulk crystal.. You say that the item is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 the compounded gabapentin powder, ketoprofen powder, and lidocaine bulk crystal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental services are 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic lumbar pain and spinal stenosis with neurogenic claudication. The record indicates that the enrollee has a body mass index greater than 40. The elements of the coverage criteria 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vytorin.
You asked the Plan to pre-approve Vytorin. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Vytorin.
Benefits for Vytorin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cholecystectomy services (47562, 47600, 47563) in an inpatient setting.
You asked the Plan to pre-approve acute inpatient hospital care. You say that it is necessary for these services to be performed at an inpatient level. The Plan denied your request. The Plan says they have agreed to cover the requested services (47562, 47600, 47563), but only at an outpatient observation level. The Plan argues that the requested surgery services are not listed on the Medicare inpatient only list, and generally enrollees do not need to spend at least two midnights in the hospital for these procedures.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient services are met in this case. Our physician reviewer found there is no clinical rationale for the requested inpatient services. The enrollee is medically stable and has received pre-operative clearance for the elective procedures. The record does not show that the admitting physician reasonably expects the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. It is not medically necessary for the requested procedures to be performed on an inpatient basis. They can be safely provided in an outpatient 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve cholecystectomy services (47562, 47600, 47563) in an inpatient setting.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found you were admitted to the hospital for surgery for a hip fracture. You are now medically stable with 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 may benefit from further therapy, you do not require an intensive therapy program in an IRF. 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.