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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically needed. The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital. The plan says that LTACH care is not medically necessary.
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 acute care hospital (ACH) after having been struck by a car. Our physician reviewer found that the enrollee suffered a cervical spine injury and right leg injury. Our physician reviewer found that the enrollee was intubated/ventilated and subsequently received a tracheotomy. Our physician reviewer found that attempts to wean the enrollee from a ventilator have been unsuccessful. Our physician reviewer found that, given the nature of the enrollee's injury, it is not certain that the enrollee will ever be able to be liberated from a ventilator or that she can be safely decannulated. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required. Our physician reviewer found that 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 10, 2019 by out of network provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your provider provided medically necessary services to the enrollee and in consideration for their services your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 subsequent
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve an oral surgical splint.You asked the Planto pre-approvethe splint. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation showing active TMJ disorder.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plandoes not haveto pre-approvean oral surgical splint
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider from April 11, 2019, to June 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 services at issue in this appeal. 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 doesnot have to pay forthe medical services provided from April 11, 2019, to June 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral Sacroiliac joint injections (SI).
You asked the Plan to pre-approve the injections. You say that the Sacroiliac Joint injections are medically necessary. The Plan denied your request. The Plan says per InterQual in order to demonstrate medical necessity for Sacroiliac Joint Injections, Sacroiliac joint disease should be confirmed by imaging. The imaging studies provided does not confirm Sacroiliac joint disease, therefore SI joint injections are not covered at this time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the established criteria for SI joint injections have not been met. There is no abnormality found on the imaging provided and it remains unclear as to what is the cause of the back pain. 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 Sacroiliac injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral Sacroiliac joint injections (SI).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRepatha Sure Injection 140mg/ml for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe medication falls under Part D coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveRepatha Sure Injection 140mg/ml for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysminimal to moderate assistance with ambulation, transfers, and activities of daily living is currently required.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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forextraction for tooth #17 (D7140) provided on May 1, 2019.You asked the Plan to pay forthe extraction. You say that you had a loose tooth that was bleeding every time you ate anything and you do not feel that you had the time to wait the 6 months. You needed the tooth out.The Plan denied your request. The Plan says you were not eligible for your first comprehensive dental service until after July 1, 2019. Per the plan benefits filings, sealants and extractions are subject to a 6 month waiting period.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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forextraction for tooth #17 (D7140) provided on May 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).You asked the Plan to pre-approveSNF admission. You saythat the enrollee is not strong enough to go home and do things on her own.The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.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 topre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatientbasis in a Skilled Nursing Facility (SNF) 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 admission have not been met.Therefore, we decided thatthe Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvefacet injections.You asked the Plan to pre-approvefacet injections. The Plan denied your request. The Plan says that the coverage criteria are not met.The Plan follows Medicare rules. Medicare rules say that if, after the first MBB injection, the patient experiences greater than or equal to 80% relief of their primary (index) pain, lasting a time period consistent with the local anesthetic used, the patient may undergo a second, confirmatory MBB.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 facet injections. Our reviewer says that the requested facet injections are medically reasonable and necessary. Our physician reviewer found that the enrollee has chronic neck and low back pain. She is taking opiates for the pain. She underwent diagnostic Left cervical MBBs on December 18, 2019, which reduced her pain from 8/10 to 2/10. The requested diagnostic blocks meet the LCD criteria of 80% pain relief and are medically 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 facet injections have been met.Therefore, we decided thatthe Plan has to pre-approvefacet injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided June 1, 2019 to June 13, 2019.You asked the Plan to pay for the SNF services. You say that you believe all services are covered and have provided the medical documentation to support the services provided to the enrollee while she resided in the facility.The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided June 1, 2019 to June 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on May 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided on May 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is not in-network with the member's Plan and the Plan has provider's that can render this service.
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 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. 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 medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Extracorporeal Pulse Activation Technology (EPAT).You asked the Plan to pre-approveEPAT procedure. You say that you have experienced constant pain and tightness in your knee, and attempted treatments have not provided relief.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because medical studies have not proven that this service is helpful for treatment of your condition.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 EPAT procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is not considered in accordance with accepted standards of medical practice for the diagnosis of treatment of your condition or to improve the function of a malformed body part. The EPAT procedure is not proven to be effective for your condition. This procedure exceeds your medical needs and is not 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 EPAT procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Extracorporeal Pulse Activation Technology (EPAT).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from June 1, 2019, to June 13, 2019.You asked the Plan to pay forthe acute inpatient hospital care. The Plandenied your request. The Plan says that the enrollee did not require acute inpatient management.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 pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then, 82-year-old female with metastatic lung cancer who recently revoked hospice care, HTN and was admitted to inpatient hospital on June 1, 2019. She had a fall at home. She was initially started on Oxycodone 10mg routine and Percocet PRN for pain and later started on IVF and subsequently Morphine drip for pain along with PRN Morphine. She also received Ativan for agitation, Haldol for delirium, and Levaquin for an infection. She progressively declined and expired June 13, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 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 the acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from June 1, 2019, to June 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services coded as D0150, D0274, and D1110 provided on May 23, 2019.You asked the Plan to pay forthe dental services. You say that when you went to this facility and provided them your insurance cards you were not informed that this dentist was not in network.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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 health plan contract says services performed by an out of network provider is not covered.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 forthe dental services coded as D0150, D0274, and D1110.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Repatha Pushtronex system.You asked the Planto pre-approve the system. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is a self-administered medication.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approve Repatha Pushtronex system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wireless capsule endoscopy.You asked the Plan to pre-approvecapsule endoscopy. You say that the enrollee is in need of this capsule endoscopy to find the source of iron deficiency anemia.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because a prior colonoscopy had found a source of bleeding whichwas treated and there is no indication that this has been evaluated for complete healing.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 capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this capsule endoscopy would be premature, relative to search for a site of gastrointestinal (GI) hemorrhage, when previously documented colonic bleeding sites have not been reassessed forhealing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of capsule endoscopy have not been met.Therefore, we decided that the Plan does not have to pre-approvea wireless capsule endoscopy.