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

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require 3-4 weeks of acute management. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 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 physician reviewer found that the enrollee was admitted to the current acute care hospital with left ankle injury after falling out of bed. His hospital course was complicated by respiratory arrest involving intubation caused by volume overload, anemia, and acute kidney injury. He appears to be more stable and requires only short-term additional acute care services, which can be safely administered at the current facility for now. He does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says there is no standard written order.
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 the scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found it is not clear that your mobility deficit impairs participation in MRADLs in the home. It is not clear that your mobility would not be able to be ameliorated by a walker, cane, or manual wheelchair. You are noted to have dementia, so it is not clear if you could safely operate the scooter, or that your home has the proper maneuvering space for the requested device. There is no detailed neuromuscular exam of the upper and lower extremities.
The criteria for the requested power mobility device has not been 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 the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight scooter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide or certified nurse assistant, providing care in the home; per hour (S9122) for 20 hours per week.
You asked the Plan to pre-approve personal care services. You say that your care is scheduled to end. You say that you will not have a caregiver to assist you. You also say that you are disabled and cannot care for yourself. The Plan denied your request. The Plan says personal care services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature.
Therefore, we decided that the Plan does not have to pre-approve home health aide or certified nurse assistant, providing care in the home; per hour (S9122) for 20 hours per week.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 services provided by an out-of-network provider on April 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport
(CPT A0998) provided on December 4, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says there is no coverage for ambulance services when transport is refused.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
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 ambulance response and treatment, no transport. Our reviewer says that ambulance response and treatment, no transport does not meet Medicare coverage criteria. Our physician reviewer found that you were diagnosed with syncope and collapse after having a glass or two of wine followed by dizziness and a fall. You did not hit your head or sustain injury. You were at baseline when emergency medical services (EMS) arrived, and you were not symptomatic. Your vitals and physical examination were essentially normal and stable.
You were offered but refused transport to the emergency department. Based on the provided documentation, you do not qualify for the CMS "treat in place" COVID-19 protocols for medically necessary ambulance services. The ambulance company did not provide transport services on December 4, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (CPT A0998) provided on December 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation services provided July 30, 2020, to August 3, 2020.
You asked the Plan to waive the copayment for the observation services. You say that since you did not request these services, you should not be held responsible for the copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $400 copayment for outpatient hospital observation. You have been asked to pay a $400 copayment for the observation services. This service falls within the outpatient hospital observation 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 the observation services provided July 30, 2020, to August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment with no transport (A0998) provided on October 10, 2020.
You asked the Plan to pay for ambulance response and treatment with no transport. You say that you did not want to go to the hospital and refused transport. You do not feel you should be responsible for the charges. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. If there is no transport, there is no covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on October 10, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no
transport (A0998) provided on October 10, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis 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 the enrollee has received two sacroiliac joint injections with very limited benefit in physical function or pain symptoms.
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 surgery. 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 post laminectomy syndrome with lumbar pain and radiculopathy as well as sacroiliitis. No imaging of the sacroiliac joint is provided, only a lumbar MRI from January 2021 that does not reveal sacroiliac pathology. Trial injections did not relieve any pain. The totality of the medical record does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.
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 not been met. Therefore, we decided that the Plan does not
have to pre-approve sacroiliac joint arthrodesis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioimpedance Spectroscopy.
You asked the Plan to pre-approve Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93702). You say that the use of this device is medically necessary. The Plan denied your request. The Plan says this elective treatment option is considered experimental, under investigation, and unproven as to the effectiveness.
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 Bioimpedance spectroscopy (BIS),
extracellular fluid analysis for lymphedema assessment(s) (93702). Our reviewer says that the requested
service is not considered medically reasonable and necessary in this case. Our physician reviewer found current
literature does not sufficiently show that this test leads to significantly improved outcomes over standard
testing and good judgement by the physician/surgeon. Therefore, this request for bioimpedance spectroscopy
and fluid analysis 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 Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema
assessment(s) (93702) have not been met. Therefore, we decided that the Plan does not have to pre-approve
Bioimpedance Spectroscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve a therapeutic CGM. You say that this requested item is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic
continuous glucose monitor (CGM).
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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been 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 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 that the patient was admitted for surgical management of a pelvic fracture after a fall.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625), for the enrollee.
You asked the Plan to pre-approve the RFA. You say that the service shows significant improvements in pain, disability, physical function, and quality of life. The Plan denied your request. The Plan says it is not medically necessary to do this procedure at the SI joint.
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 RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Furthermore, multiple other plausible pain generators including at the lumbosacral spine (and/or hip) regions) are evident. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an
exception. Therefore, the request for RFA, nerves innervation the SI joint, with image guidance (i.e., fluoroscopy or computed tomography) CPT code 64625 is not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266).
You asked the Plan to pre-approve the guided tissue regeneration (D4266). The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266
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 your doctor says you are a good candidate for inpatient rehab or some sort of rehab services. The Plan denied your request. The Plan says the criteria for an IRF are not met, and outpatient physical therapy or a skilled nursing facility would be a more appropriate for your needs.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinic visit provided on February 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that authorization was not required. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 had network providers available who could have provided 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 clinic visit provided on February 16, 2021 by an out-of-network (OON) provider.