Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FlowerAmnioFlo.
You asked the Plan to pre-approve the FlowerAmnioFlo. You say that the requested treatment is not experimental and is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
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 FlowerAmnioFlo. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has diagnoses of adhesive capsulitis of the left shoulder, shoulder pain, primary osteoarthritis, right knee pain, and myositis. Amniotic fluid injections for the treatment of joint arthropathies is in experimental phases. 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 FlowerAmnioFlo have not been met. Therefore, we decided that the Plan does not have to pre-approve FlowerAmnioFlo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 31, 2020.You asked the Plan to waive the copayment for the specialist office visit. You say that you never received services from this provider on March 31, 2020. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 copayment for in-network specialist visit.You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a skilled nursing facility follow-up visit to decrease pain medication.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 specialist office visit provided on March 31, 2020.
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 admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is making progress at home, and nothing in the therapy notes indicate that a move to SNF is needed at this time.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria on 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRetacrit.You asked the Plan to pre-approveRetacrit. You say that the requested Retacrit is medically necessary.The Plan denied your request. The Plan says the requested Retacrit is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biologicalonly 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 Retacrit. Our reviewer says that the requested Retacrit is not medically necessary. Our physician reviewer found erythropoiesis-stimulating agents (ESAs; eg, erythropoietin, darbepoetin, Retacrit) have generally not been successful in alleviating anemia associated with primary myelofibrosis (PMF). Most reported responses to ESAs are in patients with PMF who were not requiring transfusion support and/or those with inappropriately low serum erythropoietin levels. This enrollee requires frequent blood transfusion and no erythropoietin level is not provided. The service is 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 Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approveRetacrit.
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 you do not meet criteria for coverage of IRF 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 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician or acute rehab nursing care. You will not be able to tolerate the IRF level of therapies. Your rehab needs can be met at a lower intensity 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 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-approveradiofrequency ablation.You asked the Plan to pre-approvetheradiofrequency ablation. You say that the enrollee is in pain and that the requested treatment is medically necessary.The Plan denied your request. The Plan says the requested procedure is not indicated at this time.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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of lumbar spondylosis. Records do not include recent imaging studies noting abnormal results of the lumbar region. The documentation does not outline non-pharmacologic approaches to pain relief. There is no detailed physical examination. Additionally, there is not documented radiologic imaging noting structural abnormalities. It is unclear from the documentation the origin of the enrollee's pain. There is no differential diagnosis included in the record.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 pre-approveradiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two alveoloplasties in conjunction with extractions and six additional extractions of an erupted tooth or exposed roots provided on December 4, 2019.
You asked the Plan to pay for the alveoloplasties and six additional extractions of an erupted tooth or exposed roots. You say that you and your provider called the Plan and were told that these services would be covered. You also say that you feel you are entitled to the Plan covering the anesthesia. The Plan denied your request. The Plan says alveoloplasty is not a covered benefit. The Plan also says that your extractions benefit had been exhausted.
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, alveoloplasty is not among those covered under this benefit. The contract clearly states that extractions are limited to two procedures per calendar year. The record shows that you received 8 extractions on December 4, 2019, two of which were covered by the Plan, and your extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the two alveoloplasties in conjunction with extractions and six additional extractions of an erupted tooth or exposed roots provided on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left total knee replacement.
You asked the Plan to pre-approve a left total knee replacement. 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 follows Medicare rules. Medicare rules say that Medicare will consider Total Knee Arthroplasty
(TKA) medically reasonable and necessary when specific criteria is 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 a left total knee replacement. Our
reviewer says that the services are not medically necessary. Our physician reviewer found Medicare criteria
have not been met at this time. There is no current radiographic evidence of advanced joint disease. Therefore,
you do not meet the coverage criteria.
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 left total knee replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve a left total knee replacement.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxychloroquine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxychloroquine for the
enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you require intense therapy for recovery.The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician or acute rehab nursing care. You may benefit from further physical and occupational therapy, but you do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. Your needs can be met at a lower intensity setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out-of-network provider.
You asked the Plan to pre-approve the ultrasound. You say that it is necessary to have the services with this provider. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an ultrasound to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ConfirmMDx test for the enrollee.
You asked the Plan to pre-approve the testing. You say that the test was ordered in a manner consistent with
Medicare guidelines. The Plan denied your request. The Plan says the LCD requires that this test only be used
in patients with negative biopsy being considered for repeat biopsy.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee had a PSA of 10.35 ng/mL and underwent prostate biopsy using 6 cores on 5/21/2020 that
showed benign tissue. Medicare requires prostate biopsy to have 8 cores, more than were obtained on
5/21/2020. Also, Medicare requires the patient to be considering repeat biopsy in the setting of a negative
result, whereas the records did not describe an intention to repeat biopsy. Therefore, based on the
documentation provided, the enrollee is not indicated for the ConfirmMDx testing 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the ConfirmMDx test for the enrollee.
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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past medical history of Parkinson's disease, congestive heart failure, coronary artery disease, degenerative joint disease, hyperlipidemia and obesity who was admitted to the acute hospital on 07/29/2020 for an elective L4-5 lumbar laminectomy and L4-S1 fusion surgery. He underwent surgery with no reported complications. He is unsteady with balance and is limited by weakness, decreased endurance and some lethargy. He is working with physical and occupational therapy. He is walking with a front wheeled walker with minimum assistance and is moderate to maximum assist for transfers and activities of daily living. His memory and attention are noted to be impaired. He is medically stable.Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program.  Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physical therapy visits provided from February 4, 2020 to February 27, 2020.
You asked the Plan to waive the deductible for the physical therapy visits. You say that you were told many times that you did not have a copayment for your physical therapy visits. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies towards physical therapy visits and a $0 copayment after the deductible is met for each therapy visit. The physical therapy visits you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards physical therapy visits and $0 copayment after the deductible is met for each therapy visit. The record shows you met your $750 deductible on February 14, 2020 and were then charged a $0 copayment for each of the remaining physical therapy visits.
This cost sharing is a contractual obligation that had not been met at the time the physical therapy visits were received on February 4, 2020 to February 27, 2020. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy visits provided from February 4, 2020 to February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare criteria for
LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 LTACHS are certified as acute care hospitals and, in general, do not provide clinical
services that are materially different from those of short-term acute care hospitals. The enrollee is receiving
acute hospital care. The documentation does not support that the enrollee requires services at the LTACH that
are not available at the acute care hospital where he is currently receiving care. The requested LTACH services
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor Guardian Sensor 3 (HCPCS A9276).
You asked the Plan to pre-approve the services. You say that The Plan denied your request. The Plan says neither Medicare or the plan covers this monitor for everyday use or over a long period of time. The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered if they are considered therapeutic. The requested device - coded with HCPCS A9276 - is not considered therapeutic. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor Guardian Sensor 3 (HCPCS A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek test strips.
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says the services are available from preferred providers.
The Plan must follow Medicare rules. Medicare rules say that Plans can limit enrollees to preferred durable medical equipment providers. We looked at the file and Medicare rules. Accu-Chek is not the preferred provider for diabetic testing strips. The testing strips are available from the preferred provider, OneTouch. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test strips.