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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay. The enrollee was admitted after a fall for treatment of a finger fracture and a urinary tract infection. Her medical conditions are now stable. There are no complicated nursing or wound care needs. There is no documentation that the enrollee requires management three days a week by a rehabilitation physician. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There also 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. Medicare coverage criteria are not met. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on March 12, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that you disagree with the 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 $20 copayment for laboratory tests. You have been asked to pay the allowed amount of $3.28, which is less than the $20 copayment for laboratory services. Laboratory services 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 forlaboratory services provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to
be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 drug testing services provided on July 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter insertion (36573) provided on February 14, 2020.
You asked the Plan to pay for the catheter insertion. You say that you would like reconsideration because this
claim denied as a duplicate in error. The Plan denied your request. The Plan says this claim was not billed with
the appropriate modifier to indicate that the denied service was rendered during the post-operative period and
was unrelated.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 36573 is not supported in the record. Specifically, this claim was not billed with
modifier 79 which would identify CPT code 36573 as an unrelated procedure by the same physician during the
postoperative period. Based on this information, we decided that Medicare rules for coverage of the catheter
insertion have not been met. Therefore, we decided that the Plan does not have to pay for catheter insertion
(36573) provided on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary for you. The Plan denied your request. The Plan says that you were found capable of self-propelling a standard wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power scooter. Our reviewer says that a power scooter is not medically reasonable and necessary. The patient is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Our physician reviewer found that your condition does not meet Medicare criteria for a power scooter. 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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from January 18, 2020 to February 10, 2020.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee had no skilled therapy or skilled nursing service needs.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 andapply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgmentof a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from January 18, 2020 to February 10, 2020.
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 for the enrollee.
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 records do not support that member can tolerate 3 hours of daily intense therapy or that member requires complex intensive therapy.
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 that the enrollee's condition does not meet Medicare criteria for IRF care. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient does have a documented need for physical and occupational therapy, the medical record does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing rendered on March 18, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have notbeen met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing rendered on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional $60 for eyeglasses provided on March
10, 2020.
You asked the Plan to reimburse you an additional $60 for eyeglasses. You say that you only received a check
for $90, and there was no reason given as to why the remaining $60 was denied. The Plan denied your request.
The Plan says you were reimbursed the correct amount based on the routine eyewear benefit when the eyewear
is provided by a non-participating provider.
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.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were provided by a nonparticipating
provider. The Plan covers routine eyewear provided by a non-participating provider with
reimbursement up to $90 per calendar year. Therefore, we decided that the Plan does not have to reimburse
you an additional $60 for eyeglasses provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions, alveoplasty, and anesthesia services.You asked the Plan to pre-approve dental services. You say that the enrollee needs extraction of teeth in the operating room under general anesthesia.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these dental services are not covered by Medicare or the Plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve dental extractions, alveoplasty, and anesthesia services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 19, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation) requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder arthroscopy and rotator cuff repair for the
enrollee.
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no information showing a trial of physical therapy, injections or ice/heat.
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 procedures. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee presents with complaints of right greater than left bilateral shoulder pain. Clinical
exam findings have documented bilateral limited shoulder range of motion and positive right shoulder
impingement signs. There is no shoulder weakness documented. There is imaging evidence of supraspinatus
tendinosis and partial thickness tear, and moderate AC joint arthritis. There is radiographic evidence of type 1
acromion and significant AC joint arthritis. Conservative treatment has included NSAIDs and opioid
medication. Under consideration is a request for right shoulder arthroscopy and rotator cuff repair. Current
evidence based medical literature supports surgical intervention for persistent symptoms when initial
conservative treatment, including non-steroidal anti-inflammatory, injections, and exercise have failed. In this
case, detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and
failure has not been submitted. Therefore, this request for right shoulder arthroscopy and rotator cuff repair
would not be considered medically reasonable and 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 procedures have not been met. Therefore, we decided that the Plan does not
have to pre-approve a shoulder arthroscopy and rotator cuff repair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve these services. You say that the injections are needed to keep the enrollee active. 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 enrollee has bilateral sacroilitis. She has had three SI joint injections with good effect; however, the duration of pain relief was only a few days. Serial SI joint injections is not supported in peer-reviewed literature. The injections are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen (J0885).
You asked the Plan to pre-approve the Epogen. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage. The Plan also says that the documentation does not support the medical necessity for a step therapy exception.
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 the Epogen. Our reviewer says that Epogen does not meet the Plan's coverage criteria. Our physician reviewer found the Plan requires that Retacrit be used first. There is no evidence that the enrollee is allergic to or intolerant of Retacrit. Our reviewer found that there is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to why Retacrit would not be expected to be safe and effective for the enrollee. Our physician reviewer also found that the requested Epogen is not shown to be currently medically necessary and 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 Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on November 9, 2019.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids ordered through a provider other than the Plan's hearing aid provider are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a Plan hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on November 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute care.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. The patient does not require services at the proposed LTACH that are not already available at the current acute care hospital. Less than an additional 25 days of acute care is estimated based on the provided documentation which shows continued improvement and stabilization. Completion of the course of care at the current setting can be appropriately completed, then transfer to a lower level of care can be considered. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 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 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 physical therapy services to be provided by an out of network (OON) provider.