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 the enrollee needs more therapy than what was received in the skilled nursing facility, including more than 20 minutes of rehabilitation 4 or 5 times per week. The Plan denied your request. The Plan says the denial of 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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi.
You asked the Plan to pre-approve Imfinzi. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Imfinzi. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found since the enrollee has stage IV disease,
this medication is not medically reasonable and necessary per compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to
pre-approve Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits provided by an out-of-network provider from October 2, 2020, through October 30, 2020.

You asked the Plan to pay for the home visits. You say that the doctor was not responsible to get authorization since the member was in a nursing facility. You say that the provider should be reimbursed for the services rendered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and did not obtain authorization for the services.

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 the home visits provided by an out-of-network provider from October 2, 2020, through October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve the seat lift mechanism. You say that you would like reconsideration
because you have a condition which makes your legs buckle when you stand from a chair. The Plan denied
your request. The Plan says the documentation does not include a functional assessment or neuromuscular
exam.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed in the Medicare rules section are 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 seat lift mechanism. Our reviewer
says that the documentation does not reveal evidence of severe arthritis of the hip or a neuromuscular disease.
Our physician reviewer found the seat lift is not likely to improve your condition or arrest or retard
deterioration in your condition. The documentation does not reveal that you are incapable of standing from a
chair in the home.

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 seat lift mechanism have not been met. Therefore, we decided that the Plan
does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral radiofrequency ablation.

You asked the Plan to pay for the radiofrequency ablation. You say that you would like reconsideration
because the last RFA was a different procedure and rendered by a different provider. The Plan denied your
request. The Plan says inadequate relief was obtained after the initially approved procedure with the same CPT.

The Plan follows Medicare rules. Medicare rules say that Repeat thermal facet joint radiofrequency ablation
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a
minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent
improvement in the ability to perform previously painful movements and ADLs as compared to baseline
measurement using the same scale.

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 the radiofrequency ablation. Our reviewer
says that the request is considered not medically reasonable or necessary. Our physician reviewer found the
member did not achieve long lasting relief from the prior radiofrequency ablation.

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 radiofrequency ablation have not been met. Therefore, we decided that the
Plan does not have to pay for bilateral radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided record does not indicate a plan to obtain a CT scan of the chest. The requested service is not medically necessary and reasonable based upon the documentation provided. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional physical therapy visits.
You asked the Plan to pre-approve 15 additional physical therapy visits. You say that the 15 additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the 15 additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 15 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 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 for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on August 31, 2020.
You asked the Plan to pay for the eyeglasses. You say that the cost was much less expensive than any network
vendor and much less than the Plan's $200 allowance. The Plan denied your request. The Plan says the services
obtained by the member were rendered by a provider who is not contracted through our vendor.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided by the Plan's vision provider.
We looked at the file and the Plan's rules. The file shows that the eyewear was not provided by the Plan's
vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have
not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on
August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 15, 2020, by an
OON provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
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 the physician services provided on October 15,
2020, by an OON provider.
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 these services are medically necessary. The Plan
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a
lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and
atrial fibrillation and was transferred to skilled nursing facility on May 7, 2021. Your 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. Our physician reviewer found that your
condition does not meet Medicare criteria for IRF 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: Favorable

We decided that the Plan has to pre-approve a nuclear stress test.
You asked the Plan to pre-approve a nuclear stress testing procedure. You say that it is felt that this imaging is necessary to determine treatment options. The Plan denied your request. The Plan says that the enrollee's prior testing was not equivocal; therefore, further testing is not required at this time.
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 a nuclear stress testing procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has some risk factors of coronary artery disease (CAD); however, he has no chest discomfort, and his symptoms are more atypical such as fatigue and dyspnea on exertion. He did have evidence of ST depression on the stress electrocardiogram (EKG) at a moderate workload but no clinical symptoms to correlate with this. Given the lack of symptom correlation with the ST depression and the lack of classic anginal chest symptoms, there is a reasonable possibility that this could be a false positive finding on the exercise EKG. In addition, if there is ischemia, correlating the extent of the CAD with nuclear perfusion imaging to determine if invasive evaluation with cardiac catheterization is needed vs medical management makes this imaging indicated as well. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a nuclear stress testing procedure have been met. Therefore, we decided that the Plan has to pre-approve a nuclear stress test.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on December 22, 2020.

You asked the Plan to pay for the dental service. You say that code D0120 was done only once previously in 2020. You say that the plan covers 2 evaluations per year. You also say that this is the second one for this year. The Plan denied your request. The Plan says periodic oral exam and emergency diagnostic exam share a frequency limit of 2 per calendar year. The Plan also says that the frequency limit has been exceeded.

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 frequency limit has been reached. The record shows that the Plan paid for periodic oral exams that you received on February 26, 2020, and an emergency diagnostic exam that you received on July 20, 2020. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating hospital on November 5, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient surgery/in-network/outpatient hospital facility.

You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $6,473.96. The total amount you are being asked to pay is $1,294.79 ($6,473.96 x 20% = $1,294.79). An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital facility 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 coinsurance for an outpatient surgery provided by a participating hospital on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT head or brain (CPT code 70460), CT abdomen and pelvis (CPT Code 74177), CT soft tissue neck (CPT Code 70491), and CT thorax (CPT Code 71260), for the enrollee.
You asked the Plan to pre-approve the CT scans. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scans. Our physician reviewer found CT head/brain/abdomen/pelvis/neck/thorax with contrast was requested for routine imaging. The LCD states that CT scans of the head and neck are not indicated for surveillance imaging for stage I or II Large B Cell Lymphoma. No reported new symptoms or other indications for head/brain CT were documented in recent notes to justify additional CT imaging. Therefore, this request for CT head/brain 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 CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve CT head or brain (CPT code 70460), CT abdomen and pelvis (CPT Code 74177), CT soft tissue neck (CPT Code 70491), and CT thorax (CPT Code 71260), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 29, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. 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 the member's primary care physician.

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 physician services provided on September 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2020.