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

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for urosepsis and a periprosthetic hip fracture. The enrollee received antibiotics before undergoing hip revision surgery. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT Code E2311), for the enrollee.
You asked the Plan to pre-approve the power wheelchair accessory. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair accessory have not been met. It is not medically necessary to control the approved power options through the joystick (drive interface). The approved power options come with their own switches. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT Code E2311), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Flexitouch pneumatic compression device and appliances.You asked the Plan to providea pneumatic compression device (E0652)and appliances.You say that the enrollee needs the Flexitouch pneumatic compression device to prevent further progression of the lymphedema.The Plan denied your request. The Plan says a basic pump use must be for 4 weeks,for many hours a day,nearly every day.The Plan followsMedicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 orE0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to providea Flexitouch pneumatic compression device and appliances.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Transit Securement Package.
You asked the Plan to pre-approve the Transit Securement Package. You say that the enrollee needs a Group 2 power wheelchair and all accessories. The Plan denied your request. The Plan says the hardware transit kit is for outside the home and not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature and is for use outside the home. This item is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the Transit Securement Package.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on August 27, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says progress notes are needed in order to determine the clinical utility of the testing.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there were insufficient records providedto show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Based on this information, we decided that Medicare rulesfor coverage have not been met. Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on August 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from February 1, 2019 to March 2, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate settingother than a SNF.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from February 1, 2019 to March 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar decompression and spinal fusion.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says no MRI was performed, and other pain generators were not identified or ruled out.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of worsening back pain. He is status post L4/5 decompression and fusion and subsequent spinal cord stimulator implantation. Functional limitations are noted in activities of daily living. Clinical exam findings do not evidence a focal neurologic deficit. There is bone scan and radiographic evidence of disc and facet degeneration at the L3/4 and L5/S1 levels, trace retrolisthesis with no dynamic instability, and some increased update at L4/5. He has reportedly exhausted conservative treatment with facet injections and radiofrequency ablations, documented in 2018. It was noted that the L5/S1 disc is almost completely gone (auto-fused). Under consideration is a request for L3/4 extreme lateral interbody fusion and pedicle screws from L3 to S1, and evaluation of his L4/5 fusion intraoperatively. Current evidence based medical literature generally supports decompression and fusion for adjacent segment disease. However, there is no clear imaging evidence of spinal stenosis, nerve root impingement, or neuroforaminal stenosis consistent with adjacent segment disease at the L3/4 or L4/5 levels. There are no clinical findings of neurologic deficits or signs/symptoms consistent with neurogenic claudication. It is not clear that the source of pain generation has been confirmed. Additionally, the medical necessity of an XLIF fusion has not been clearly supported. Therefore, this request for lumbar decompression and fusion is not medically reasonable and necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar decompression and spinal fusion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on April 25, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed; therefore the billed test cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to enrollee on April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on May 4, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on May 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract laser surgery (66821) provided on July 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for cataract laser surgery. You say that you did not realize these services required authorization. The Plan denied your request. The Plan says out-of-network services require prior authorization.
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 for the cataract laser surgery (66821) provided on July 15, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy.
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is only covered when part of a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that PILD will only be covered by Medicare when provided in a clinical study. We looked at the file and Medicare rules. The records do not show that the coverage criteria are met, as the enrollee is not enrolled in a clinical trial for the requested procedure. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the gynecological services (G0101 and 81002). You say that you were unaware that authorization was required because the member presented you with incorrect insurance information. The Plan denied your request. The Plan says utilization of network providers is required unless the Plan pre-approves out of network services in non-emergent situations.
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 for the medical services provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device and appliances to be provided by an out of network provider.
You asked the Plan to pre-approve the out-of-network pneumatic compression device and appliances. You say that the enrollee needs the pneumatic compression device and appliances. The Plan denied your request. The Plan says the pneumatic compression device and appliances can be provided 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 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 the pneumatic compression device and appliances to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the scooter carrier for car (A9270).
You asked the Plan to pre-approve the scooter carrier for car. You say that you got a scooter due to having neuropathy. You cannot drive the scooter on the street and that is why you need the lift for your car but you do not know why this is being denied. The Plan denied your request. The Plan says this item is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the scooter carrier for car (A9270).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProlia 60 mg/ml subcutaneous injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy guidelines must be followed.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has tried Ibandronate buthas not tried Zoledronic acid. The provider does not state that Reclast (Zoledronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee 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 the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProlia 60 mg/ml subcutaneous injection.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency room services (81002, 74018, 87086) provided on October 10, 2019. You asked the Plan to waive the copayment forthe emergency room services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment 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 a $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency 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 foremergency room services (81002, 74018, 87086) provided on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 very heavy duty POV, patient weight capacity 451-600 pounds (K0802).
You asked the Plan to pre-approve the very heavy duty POV (K0802). You say that the POV is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for the very heavy duty POV have not been met.
The Plan follows Medicare rules. Medicare rules say that a very heavy duty POV coded as K0802 is covered for a beneficiary weighing between 451 and 600 pounds. The file shows that the enrollee does not meet the weight requirements for the Group 1 POV (K0802). This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 very heavy duty POV, patient weight capacity 451-600 pounds (K0802).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on September 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered to the enrollee on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on May 7, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 nurse practitioner services provided on May 7, 2019.