Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 10 additional physical therapy visits.
You asked the Plan to pay for 10 additional physical therapy visits. You say that the progress notes reflect the enrollee's functional status and the need for continued skilled therapy. The Plan denied your request. The Plan says the additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 10 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy and was trained in a home exercise program. Our physician reviewer also found that the ongoing unique skills of a professional therapist are not needed to safely and effectively provide treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pay for 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implanted tooth removal, partial mandibular dentures, and periodontal scaling for the enrollee. You asked the Plan to pre-approve the services. You say that the dental treatment is necessary. The Plan denied your request. The Plan says the x-rays do not show the need for bone removal or sectioning of the tooth. There appears to be 8 or more natural or prosthetic posterior teeth in occlusion. 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 services 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 services. Our reviewer says that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the documentation provided does not meet the criteria for coverage for a surgical extraction of tooth #7, scaling and root planing of four quadrants and a mandibular removable partial denture. A review of the enrollee's dental records and radiographs indicate that periodontal scaling and root planing was done less than 24 months ago. The radiographs provided do not show that the enrollee has multiple missing posterior teeth to warrant a partial denture; the masticatory function appears adequate. There was no radiograph of tooth #7 to determine if a surgical extraction which involves bone removal is necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve implanted tooth removal, partial mandibular dentures, and periodontal scaling for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of torus mandibularis (D7473) surgical extraction (D7210) and extraction (D7140) provided February 17, 2020.
You asked the Plan to pay for the dental services. You say that your physician told you that all your teeth needed to be removed to prevent poisoning your heart. You request reimbursement because the services performed were medically necessary. The Plan denied your request. The Plan says this service exceeds the maximum allowable.
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 allows a $200 annual allowance. You are responsible for any amount above the coverage limit. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for removal of torus mandibularis (D7473) surgical extraction (D7210) and extraction (D7140) provided February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says medically necessary care is 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 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 referral to an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN in the home health or hospice setting and the additional services performed by a qualified occupational therapist in the home health or hospice setting.You asked the Plan to pre-approve the home health services. You say that these services are medically necessary for you.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that these services do not meet the Plan's coverage criteria. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. There is no documentation of complex wound care or other skilled nursing need. You have had disease education and the documentation does not reveal that your medical condition or management needs the skills of a professional nurse. Our reviewer found that the documentation notes that despite therapy, you are having more discomfort and you are following up with your physician. Our physician reviewer also found that you should be able to transition to a home exercise program until further treatment plans from your physician are made.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 home health services have not been met.Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a RN in the home health or hospice setting and the additional services performed by a qualified occupational therapist in the home health or hospice setting.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need this because of her fractured spine and pelvis. The Plan denied your request. The Plan says you could be treated at an alternate level of care.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you have any identifiable skilled nursing service needs. While you have skilled therapy needs, you do not need therapy on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastric bypass.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this procedure is safe and helpful for treatment of the health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published data to support gastric bypass for you, particularly when BMI is so low - 18 kg/m2. It is possible that gastric bypass will help with gastroparesis but would still result in unintended weight loss and therefore could be problematic for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a gastric bypass.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for physical therapy at an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says there was no clinical documentation submitted that indicates the medical necessity of this request with an out-of-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 referral for physical therapy at an out-of-network provider.
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 are in pain and need rehabilitation.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical therapy and occupational therapy, based on the records provided youdo not require an intensive rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level is more appropriate.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hereditary colorectal cancer susceptibility screening testing.
You asked the Plan to pre-approve genetic screening testing. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the Plan did not receive a 3-generation pedigree to determine if the enrollee would meet guidelines for testing.
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 genetic screening testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's history does not raise a high suspicion for Lynch Syndrome or colorectal hereditary genetic testing. She has a history of endometrial cancer and only other cancer history is breast cancer in 1 family member. In addition, mismatch repair (MMR) and microsatellite instability (MSI) is listed as wild type. None of these meet criteria for testing for colorectal cancer susceptibility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic screening testing have not been met. Therefore, we decided that the Plan does not have to pre-approve hereditary colorectal cancer susceptibility screening testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network orthopedic spine surgeon.
You asked the Plan to pre-approve the continuation of care with an out of network orthopedic spine surgeon. You say that the out of network provider being requested is familiar with the enrollee's complex back condition, symptoms, and prior surgeries/procedures. You say that the enrollee wishes to maintain a continuity of care. The Plan denied your request. The Plan says the requested doctor is not within the plan network. The Plan says that there are in-network providers who are able to treat the enrollee's conditions.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 continuation of care with an out of network orthopedic spine surgeon. Our reviewer says that the criteria for out of network care have not been met. Our physician reviewer found the enrollee presents with chronic low back pain and lower extremity weakness. She has been diagnosed with lumbar spinal stenosis with neurogenic claudication.
She is status post lumbar decompression and fusion surgeries (at the L3/4 and L4/5 levels) most recently in 2015. She is currently reporting worsening leg weakness and dysfunction. She last saw the requested orthopedic spinal surgery on May 18, 2018. This orthopedic spine surgeon is no longer under contract and has apparently advised the enrollee to establish care with an in-network orthopedic spine surgeon. The Health Plan denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network orthopedic surgeon. There is nothing unique about her condition that would make it medically necessary for her to see the requested out-of-network provider. The Health Plan has shown that they have in-network providers who meet the standards of care for treatment of her medical condition. The enrollee is not currently receiving active treatment and/or medical management of her condition that made it medically necessary for her to continue care with the out of network orthopedic surgery provider. This enrollee's medical management and/or follow-up care be safely transitioned to an in-network orthopedic surgery specialist 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 continuation of care with an out of network orthopedic spine surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network orthopedic spine surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
You asked the Plan to pre-approve TMS. You say that the enrollee has been struggling with his conditions since he was a child but does not think he can go through with therapy. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not had a trial of therapy to treat his condition and the recommended level of care is outpatient services.
The Plan follows Medicare rules. Medicare rules say that TMS is only covered for enrollees who meet the specific clinical criteria listed above, including undergoing a trial of psychotherapy. 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 TMS. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of TMS. Our physician reviewer found the enrollee has not undergone a trial of psychotherapy for the treatment of his condition, therefore this TMS is not considered 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 TMS have not been met. Therefore, we decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for the enrollee.
You asked the Plan to pre-approve the referral. You say that the enrollee needs an HMO exception. The Plan denied your request. The Plan says very little clinical information was received to show why out-of-network services are needed.
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 referral to an out-of-network provider for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient setting is more appropriate because of your conditions. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because you do not meet the criteria for inpatient level of care and an observation stay is appropriate.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the co-morbidities for your planned surgery are listed as hypothyroidism, nicotine dependence, depression, and chronic obstructive pulmonary disease (COPD) which, based on the submitted records, is non-oxygen dependent and managed as needed with drugs. No other specific rationale for inpatient admission is noted. The record does not show that the admitting physician reasonably expects that your necessary hospital care will span at least 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings due to recurrent deep vein thrombosis and because standard stockings do not fit. The Plan denied your request. The Plan says you do not meet coverage criteria because you do not have a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.