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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve the SNF admission. You say that you feel that due to your intensive surgery, you require daily skilled therapy. The Plan denied your request. The Plan says your pain is controlled with Tylenol and gabapentin and there are no complex wound care needs. You can reach functional goals with less than daily skilled therapy services. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 77-year-old male with diabetes, hypertension who underwent a planned right total hip arthroplasty revision. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a contact guard assist level with functional mobility including gait to 15 feet x 2 with a rolling walker. The beneficiary required varying assist with ADLs. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, daily skilled therapy is not required. This beneficiary does 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pontic - porcelain fused to predominantly base metal
(D6241) and abutment supported porcelain fused to metal crown (predominately base metal) (D6060) provided
on October 18, 2019.
You asked the Plan to pay for the dental services. You say that in July of 2017 you had an operation for a
tumor and jaw reconstruction that was paid your employer health insurance. You state that you were told you
had to wait for one year for it to heal and in July 2018, you saw an oral surgeon for implants. The Plan denied
your request. The Plan says you received your primary service in July of 2017. The Plan states Medicare does
not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted
in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly
repairing teeth or structures directly supporting teeth (e.g., alveolar process).
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for pontic - porcelain fused to
predominantly base metal (D6241) and abutment supported porcelain fused to metal crown (predominately
base metal) (D6060) provided on October 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH admission is medically necessary.The Plan denied your request. The Plan says continued management can be provided at the Skilled Nursing Facility level of care once acute level of care is no longer necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found additional weaning off oxygen supplementation can be completed at the current facility. The member does not require services at the proposed LTACH that are not already available at the current acute care hospital setting. The member appears stable enough for discharge to a lower level of care soon after a short additional stay at the current facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a thyroid uptake nuclear imaging study.
You asked the Plan to pre-approve the thyroid imaging. You say that the enrollee needs this imaging in order to
measure uptake so that definitive treatment with radioactive iodine can be administered and dosed properly.
The Plan denied your request. The Plan says that the enrollee does not have high thyroid hormones on testing
so this imaging is not needed.
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 thyroid imaging. Our reviewer says
that the requested imaging is considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has a history of Grave's disease as is taking methimazole. She is no longer
tolerating this treatment and treatment with radioactive iodine (RAI) is planned. In order to dose the RAI
correctly, a radioactive iodine uptake is needed. It is not being done to diagnose the etiology of
hyperthyroidism as is often done with the information from a scan and uptake. In this case, rather, it is being
done to determine how much RAI needs to be given to ablate the thyroid. Without this information, there is a
risk that the RAI will not ablate the thyroid. As such, this imaging is considered medically reasonable and
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 thyroid imaging have been met. Therefore, we decided that the Plan has to
pre-approve a thyroid uptake nuclear imaging study.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the routine transportation trips. You say that all of your rides were used up
and that you want to appeal for more. The Plan denied your request. The Plan says the benefit for routine
transportation 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 48 one-way routine transportation trips for enrollees with chronic
conditions.
We looked at your request, the records in the case file, and the rules. The records show that you have chronic
conditions, including diabetes and chronic obstructive pulmonary disease. The records also show that you have
received coverage for 48 one-way routine transportation trips. Based on this information, we decided that you
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that
the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bladder catheter insertion provided by a participating provider on February 24, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you did not have any surgery. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $200 copayment for outpatient surgery. You have been asked to pay $135.59 which is less than your copayment amount of $200 for an outpatient surgery. The services that were provided are considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery 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 a bladder catheter insertion provided by a participating provider on February 24, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve spine surgery (C3-5 ACDF) for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not medically necessary.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 surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee presents with progressively worsening neck pain radiating into the right upper extremity with weakness and paresthesias since a fall on 2/27/20. She reports hand weakness and dropping objects. Neurologic exam documented motor deficits consistent with imaging evidence of severe foraminal stenosis at the C3/4 and C4/5 levels, and cord flattening at C3/4. There is reported radiographic evidence of grade II spondylolisthesis at C3/4 and grade 1 spondylolisthesis at C4/5, with motion at C3/4 on flexion/extension. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure, including activity modification, medications, epidural steroid injection, radiofrequency ablation, and home therapy, has been submitted. Under consideration is a request for C3-C5 anterior cervical discectomy and fusion. Current evidence based medical literature supports anterior cervical discectomy and fusion for patients with cervical radiculopathy that have failed conservative treatment and have progressive neurologic symptoms. This enrollee presents with progressive worsening cervical radiculopathy with motor deficits correlated with imaging evidence of cord flattening and severe foraminal stenosis at the C3/4 and C4/5 levels. Therefore, this request for C3-C5 anterior cervical discectomy and fusion is medically reasonable and 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 surgery have been met.Therefore, we decided that the Plan has to pre-approve spine surgery (C3-5 ACDF) 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: 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 health and recovery of the enrollee will be adversely affected if IRF care is denied. You say that the enrollee meets the criteria forcoverage of IRF care and is at equilibrium regarding stability and acute needs. You say that the enrollee will benefit from IRF services that cannot be accomplished at a lower level of care.The Plan denied your request. The Plan says the guidelines forcoverage of IRF care have not been met. The Plan says that the care needed can be 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 above.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 enrollee admitted to the hospital with a COPD exacerbation. On July 20, 2020, the physician documents that, based on the evaluation that day, the enrollee's functional status does not warrant acute intensive inpatient level of rehabilitation. The documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complex outpatient therapeutic radiology treatment planning for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is met for 3D-CRT, and this would be approved if requested.
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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found SBRT in general is not an accepted standard of care (in lieu of other standard of care radiotherapy) for the adjuvant treatment of breast cancer. The NCCN guidelines (v5.2020) recommend standard 10-fraction dosing: 34 Gy in 10 twice-daily fractions with brachytherapy or 38.5 Gy in 10 fractions with 10 twice-daily fractions. The guidelines state: "other fractionation schemes are currently under investigation." 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve complex outpatient therapeutic radiology treatment planning for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic blood pressure monitor (A4670) purchased on
January 17, 2020 from a non-participating provider.
You asked the Plan to pay for automatic blood pressure monitor. You say that you are requesting
reimbursement of services rendered. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pay for automatic blood pressure monitor (A4670)
purchased on January 17, 2020 from a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99307, 99308) provided
on January 7, 2020 and January 21, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of
network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan
does not have to pay for the subsequent nursing facility care (99307, 99308) provided on January 7, 2020 and
January 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on January 10,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the claim came from an out-of-network provider, and authorization for seeing this provider was
not granted.
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 has network providers
available who can provide 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 home health services provided to the enrollee on
January 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you suffer several health conditions and are
not ready to go home until your health is more stable. The Plan denied your request. The Plan says the enrollee
is not shown to need more skilled therapy, complicated wound or medical care, or a need to receive antibiotics
through the veins that cannot be done at home. The Plan says that the enrollee can have services rendered in
home or at a different type of facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, and clear lungs. The enrollee received physical therapy and occupational
therapy. The enrollee was at a two-person moderate to maximal assist level with bed mobility and transfers.
The enrollee required varying assist with activities of daily living. There are no identifiable skilled therapy
service needs. There are no identifiable skilled nursing service needs.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 15, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the services received were not authorized and
are not payable
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 has network providers
available who can provide 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 the medical services provided on October 15, 2019
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), expandable controller (E2377) with the related electronic connection and harness (E2311/E2313).
You asked the Plan to pre-approve these additional power wheelchair components. You say that the enrollee needs this power wheelchair. The Plan denied your request. The Plan says the requested power seating system is not covered by Medicare. In addition, the requested expandable control is not needed as the enrollee is able to use the individual switches for the power tilt/recline, and power elevating leg rests.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered by Medicare. Non-expandable controls allow for up to two power seating actuators to be controlled. In this case, there is no evidence that an expandable controller is needed as the requested chair only has two covered power seating features. A non-expandable control with the required connections may be coverable if requested. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), expandable controller (E2377) with the related electronic connection and harness (E2311/E2313).