Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is needed due to rheumatoid arthritis, bilateral knee pain, and osteoporosis. The Plan denied your request. The Plan says there is no order in the provider notes for an electric bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found your condition does not require positioning of the body in ways not feasible in an ordinary bed. There is no documentation that you require frequent changes in body position or immediate changes in body position. Your condition does not require special attachments that cannot be fixed and used on an ordinary bed. 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging, (MPI) SPECT stress test (78452).
You asked the Plan to pre-approve the MPI SPECT stress test. You say that please find the attached documentation. The Plan denied your request. The Plan says the enrollee is not eligible for coverage based on the Medicare criteria.
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 MPI SPECT stress test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has no cardiopulmonary symptoms and can walk 5 miles without symptoms. She reports some occasional dizziness but no palpitations. She has evidence of LAD calcification on a low dose CT scan, and she is being appropriately treated with risk factor modification with statins, blood pressure lowering and lifestyle modification for this. She has no known prior symptomatic atherosclerotic cardiovascular disease and no prior positive stress testing or prior cardiac revascularization
procedures. Her LVEF is normal by echo as is her carotid duplex ultrasound study. A prior nuclear stress test was negative for ischemia in 2018 and there are no reported baseline EKG abnormalities affecting the interpretation of the EKG. Based on these findings and her only clinical symptoms of occasional non-specific dizziness with no chest symptoms or dyspnea to suggest angina with exertion or at rest, she would not meet any of the applicable CMS LCD (L33560) indications for nuclear cardiac stress imaging 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 MPI SPECT stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, (MPI) SPECT stress test (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat lift chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says there are household modifications in place to assist with sit-to-stand transfers.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the chair. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no documentation that a seat lift is included in the treating practitioner's course of treatment. There is no documentation that the seat lift will affect improvement in your condition or arrest or retard deterioration in your condition. There is no documentation that you are is completely incapable of standing from a chair in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a folding wheeled walker (E0143) and a knee brace (L1833) provided on March 8, 2021.
You asked the Plan to waive the cost-sharing for a folding wheeled walker and a knee brace. You say that the hospital is compensated in some manner for dispensing the brand of the items at issue and therefore these items should not be billed separately. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered durable medical equipment and for each Medicare-covered prosthetic
device. Your contract also says that there is a $400 deductible applicable to durable medical equipment and prosthetic devices. You have been asked to pay a $400 deductible and $32.77, or 20% of the Medicare-allowed charge of $163.84 remaining after the application of the deductible, for a folding wheeled walker and a knee brace. A folding wheeler walker falls within the "Durable Medical Equipment (DME) and Related Supplies" benefit category. A knee brace falls within the "Prosthetic Devices and Related 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 cost-sharing for a folding wheeled walker (E0143) and a knee brace (L1833) provided on March 8, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard you received on March 8, 2021.
You asked the Plan to pay for the occlusal guard. The Plan denied your request. The Plan says this 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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Occlusal guards are not covered. Therefore, we decided that the Plan does not have to pay for the occlusal guard you received on March 8, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for tooth #'s 6, 7 and 10. 
 
You asked the Plan to pre-approve the crowns. You say that 6 teeth were submitted but only 3 were approved. 
You say that you have cancer and needs crowns for all of your teeth. The Plan denied your request. The Plan 
says the teeth have sufficient tooth structure remaining therefore the crowns are not medically necessary. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.

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 crowns. Our reviewer says you're 
your dental record and radiographs indicate that tooth #'s 6, 7 and 10 do not appear to have significant coronal 
breakdown due to caries or fracture to warrant crown restorations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns for tooth #'s 6, 7 and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on December 18, 2020 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 12, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 14301, 14040, and 14302 are not supported.
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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14040 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure).
We find that CPT codes 14301, 14040, and 14302 are not supported in the medical record. Specifically, there is no documentation of adjacent tissue transfer of any area of 30.1sq cm to 60 sq cm to support code 14301. There is no documentation of adjacent tissue transfer of the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet of 10sq cm or less to support code 14040. There is no documentation of adjacent tissue transfer of any area for each additional 30 sq cm to support code 14302. 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 pay for the surgical services rendered on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care after 
August 12, 2021. 
 
You asked the Plan to pre-approve the continued inpatient care. You say that these services are necessary and 
should be approved. The Plan denied your request. The Plan says the care has been approved from July 9, 
2021, to August 11, 2021, but as of August 12, 2021, the enrollee's condition had improved to a point where 
they could have been moved to a less intensive level of outpatient care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued care. Our reviewer says 
that the inpatient psychiatric care was not medically necessary after August 12, 2021. Our physician reviewer 
found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on July 9, 2021, on an 
involuntary basis. The enrollee was treated under an individualized treatment plan found in the record. It did 
appear that the records were supervised and evaluated by a physician. Based upon review of the records 
provided for the admission, the criteria for continued acute inpatient mental health treatment for the dates in 
question of August 12, 2021 forward are not met. This enrollee was not shown to be a danger to themselves or 
others. They did not show any auditory or visual hallucinations and were cooperative and compliant with 
treatment. The enrollee was not showing any aggressive behaviors and because of this, it does not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level rather than a 
lower level of care beyond the dates in question.  
 
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 continued care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric hospital care after August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 19,
2021.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges
because this was your annual physical. 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 $10
copayment for primary care physician services.
The medical records show that you received services beyond an annual wellness exam on January 19, 2021.
Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the
physician/practitioner services, including doctor's office visits 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 an office visit provided on January 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve colonoscopy. You say that you are in pain and have Lynch Syndrome. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can receive a colonoscopy from 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-approve a colonoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are ready to leave the hospital, but you need to regain more strength before you can go home. You say you need intensive therapy. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87150) provided on December 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not
supported.
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 87150 is "Culture, typing; identification by nucleic acid
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed".
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 services. Our reviewer says that the use
of code 87150 is not supported by the records provided.
Our physician reviewer found that the provided records do not support that urine culture and typing by nucleic
acid probe, 12 units, was performed.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (87150) provided on December 21, 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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has completed the full course of care in the hospital, and a long-term plan has not yet been determined for their care. It is not documented that doctors expect the enrollee to improve in an LTACH at this point. The enrollee can remain in the current acute care hospital to finish treatment.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available and covered 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 and able to be furnished safely and effectively only
on an inpatient basis. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Supartz FX 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX.