Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral for services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe referral. You say that you would like reconsideration because you have read that this provider is a very good doctor.The Plan denied your request. The Plan says the records do not show that you cannot receive proper care with an in-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-approvea referral for services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) for spinal levels C7-T1.
You asked the Plan to pre-approve the ESI. You say that the enrollee would benefit from this injection to treat her pain. The Plan denied your request. The Plan says the documentation only shows short pain relief from prior ESI.
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 ESI. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 56-year-old woman has chronic neck pain. She had an MRI in 2019 that showed mild central cervical stenosis, mild neuroforminal stenosis and facet arthropathy. She has had Physical Therapy and medication trials. She had a prior cervical interlaminar epidural steroid injection which provided her with 3 weeks of pain relief. Changes in medication use or functionality are not documented. The physical exam does not document motor, sensory or reflexes. There is no documentation of Hoffman's reflex or other abnormal neurological findings. The request is for a repeat epidural steroid injection. The prior epidural steroid injection results are not well documented and there is little documentation of any current cervical radiculopathy. The request 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 ESI have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) for spinal levels C7-T1.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93926) provided on April 11, 2020.
You asked the Plan to pay for the duplex scan. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the definition of the diagnosis code and the
CPT code, localized edema is a general diagnosis and does not support the procedure for a duplex scan of the
lower extremity arteries or arterial bypass grafts.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
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 duplex scan. Our reviewer says that this
claim was not reported with an appropriate diagnosis code. Our physician reviewer found the limited
documentation supports that Duplex scan of the lower extremity venous system would have been appropriate
for the diagnosis code submitted.
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 duplex scan have not been met. Therefore, we decided that the Plan does not
have to pay for a duplex scan (93926) provided on April 11, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay fortendon repair (27658) provided on December 19, 2019.You asked the Plan to pay forthe tendon repair. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the documentation does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27658 is repair, flexor tendon, leg; primary, without graft, each tendon 27658.We asked our coder 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 tendon repair. Our reviewersays that CPT code 27658 meets criteria for billing and reimbursement consideration. Our reviewer found in the operative note the provider repaired the Brevis tendon. The Brevis tendon is located directly behind the fibula bone and is a flexor tendon. The area was then flushed with copious amounts of sterile saline solution.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tendon repair have been met.Therefore, we decided that the Plan has to pay fortendon repair (27658) provided on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint fusion.
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the requested sacroiliac joint fusion is
medically necessary. The Plan denied your request. The Plan says the requested sacroiliac joint fusion is 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 sacroiliac joint fusion. Our reviewer
says that the requested sacroiliac joint fusion is not medically necessary. Our physician reviewer found the
enrollee is with low back pain and bilateral radiculopathy. SI joint fusion is not medically needed. There is no
documented SI joint instability, fracture or lesion. SI fusion for back pain is experimental.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan
does not have to pre-approve sacroiliac joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for seat lift mechanism, electric (E0627) purchased January 9, 2020.
You asked the Plan to pay for the seat lift mechanism. You say that you have been calling the plan since January and haven't gotten anywhere and then all of a sudden you get a letter of denial . The Plan denied your request. The Plan says based on Medicare guidelines, this request is not medically necessary.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above 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 pay for the seat lift mechanism. Our physician reviewer found that, based on the medical records provided, there is no documentation that the enrollee has severe arthritis of the hip or a neuromuscular disease. There is no documentation that a seat lift is included in the treating practitioner's course of treatment or that a seat lift is likely to effect improvement in the enrollee's condition or arrest or retard deterioration in the enrollee's condition. There is no documentation that the enrollee is completely incapable of standing from a chair in the home and based on the medical records provided there is documentation that the enrollee has the ability to ambulate. 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 pay for seat lift mechanism, electric (E0627) purchased January 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that the requested bone marrow aspiration is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration is 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 bone marrow aspiration. Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee has ongoing radicular back pain and L5/S1 anterior segment spondylolisthesis/foraminal stenosis and L3/4 adjacent segment degeneration with severe stenosis and lateral spondylosthesis. Bone marrow aspiration remains experimental in cases of spinal fusion. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveaspinal electrical osteogenesis stimulator.You asked the Plan to pre-approvea spinal electrical osteogenesis stimulator. You say that this is medically necessary.The Plan denied your request. The Plan says that you do not meet criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered if you meet the above criteria.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 spinal electrical osteogenesis stimulator. Our reviewer says that a spinal electrical osteogenesis stimulator id not considered medically reasonable and necessary in this case. There is only an L3-4 level fusion which is only 1 level above a previous L4-S1 fusion. Our physician reviewer found that your condition does not meet Medicare criteria for a spinal electrical osteogenesis stimulatorWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal electrical osteogenesis stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal electrical osteogenesis stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says an intensive team is not needed for 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 the enrollee was medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally she will not be able to tolerate therapies 3 hours a day and hence does not require IRF level of therapies. The enrollee may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current activity tolerance status and medical stability. Pre-and-Post dialysis she will not be able to participate and benefit from IRF therapies. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are not reasonable and necessary.
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 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 not require an intensive inpatient rehabilitation therapy program. 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. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on December 2, 2019.
You asked the Plan to pay for anesthesia. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for anesthesia provided on December 2, 2019.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 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. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October 7, 2019 to December 26, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided on October 7, 2019 to December 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 & D5120).
You asked the Plan to pre-approve the complete upper and lower denture (D5110 & D5120). You say that you have no teeth. You say that you cannot eat certain foods, your gums are irritated, and you are in pain. The Plan denied your request. The Plan says the $230 quarterly benefit has been used.
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, there is a maximum allowance of $230 per quarter. The complete upper and lower denture were denied because at the time of the request you had met the quarterly maximum. If you have not used your current quarterly maximum, that amount may be applied toward these services. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 & D5120).
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. The Plan denied your request. The Plan says that care can be continued at higher level of care in acute inpatient hospital due to unstable cardiovascular status.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OmniSeq Advance panel.
You asked the Plan to pay for the OmniSeq Advance panel. You say that the OmniSeq Advance panel provided
was medically necessary. The Plan denied your request. The Plan says the OmniSeq Advance panel provided
was 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 pay for the OmniSeq Advance panel. Our reviewer
says that the OmniSeq Advance panel provided was not medically necessary. Our physician reviewer found the
enrollee is diagnosed with head and neck squamous cell carcinoma. First line drug is carbo/5fu/keytryda or if
pdl1+ keytruda. Thus further molecular testing not reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the OmniSeq Advance panel have not been met. Therefore, we decided that the
Plan does not have to pay for the OmniSeq Advance panel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided from February 28, 2020 to March 3, 2020.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you were charged for a semi-private room without being asked.The Plan denied your request. The Plan says that you were charged correctly.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 $345 copayment per day, days 1 to 4 of Inpatient hospital care. You have been asked to pay a $1,380 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 4 of Inpatient hospital care 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 forthe inpatient hospital services provided from February 28, 2020 to March 3, 2020.