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

We decided that the Plan does not have to pre-approve continued inpatient hospital care after July 9, 2020.You asked the Plan to pre-approve acute inpatient hospital care. You say that continued inpatient care is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met in a lower acuity setting.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 services are met in this case. Our physician reviewer found the enrollee has been stabilized and determined safe for transfer to a skilled nursing facility. Records support the facility has been working to transfer the enrollee to a skilled nursing facility approved by the family. Records do not support ongoing care meets inpatient medical necessity.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 continued inpatient hospital care after July 9, 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 the services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. The
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of prostate cancer. There is no compelling data to suggest that proton therapy is superior to or more beneficial than intensity modulated radiation therapy (IMRT) or image guided radiation therapy (IGRT). Proton therapy would exceed the needs of the enrollee and is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Radiofrequency Ablation Procedure (64454, 64624).You asked the Plan to pre-approvethe ablation procedure. You say that the service is medically necessary for the enrollee's knee pain.The Plan denied your request. The Plan says the procedure is considered investigational for this 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 the ablation procedure. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found there is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of these procedures for the enrollee's condition 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 ablation procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea Radiofrequency Ablation Procedure (64454, 64624).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on March 7, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysComprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation) requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be coded with CPT 81479.The testing at issue in this case should have been coded with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on March 7, 2020.
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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says your records do not show you need intense rehab services.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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 20, 2019.You asked the Plan to pay for the laboratory 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 laboratory services.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 laboratory services provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires frequent neurological checks, physician monitoring, and rehab.The Plan denied your request. The Plan says the enrollee is unable to participate in 3 hours of therapy a day.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 requestto pre-approve IRF care. Our physician reviewer found that the enrollee's current level of function is minimal assist for standing, and minimal to total assist for activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from physical and occupational therapy, but the documentation does not support that his functional status and endurance level requires an 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of velaglucerase alfa (VPRIV) in an external infusion pump.You asked the Plan to pre-approveVPRIV. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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 arecovered by Medicare Part B.Furthermore, the request for use of VPRIV in an external infusion pump does not meet Medicare's specific criteria for coverage under the Durable Medical Equipment (DME) benefit. Therefore, we decided that the Plan does not have to pre-approveuse of velaglucerase alfa (VPRIV) in an external infusion pump.Benefits for VPRIVmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar fusion.
You asked the Plan to pre-approve the requested fusion. The Plan denied your request. The Plan says there is no evidence of an unstable joint.
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 requested fusion. Our physician reviewer found that the medical records do not document failure of the previous L5-S1 fusion. There is no evidence of spinal instability, fracture or lesion. Therefore, the requested services are not 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 the requested fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care (99224) provided December
11, 2019.
You asked the Plan to pay for the subsequent observation care. You say that the claim denied for no
authorization. Therefore you are appealing the claim with the medical records and denied EOB. The Plan
denied your request. The Plan says payment for observation care codes is for all the care rendered by the
ordering physician on the date(s) the patient is in an observation status and may only be reported once per day.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary
covered services to the beneficiary either directly or under arrangements made with outside providers. You
provided physician services to the enrollee while in observation status in a facility. Payment for this service
would have been included under the facility claim for observation. Payment to you for this service is the
responsibility of the facility or hospital. Therefore, the plan is not required to pay you separately for this claim.
Therefore, we decided that the Plan does not have to pay for the subsequent observation care (99224) provided
December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have topre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that your doctors feel this provider would be best.The Plan denied your request. The Plan says the services are available from network providers.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. The Plan has tertiary level providers that are equipped to provide the same level of care as the requested provider. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck.
You asked the Plan to pre-approve the MRI of the neck. You say that the requested MRI is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI of the neck. Our reviewer says that the MRI which remains in dispute is not medically reasonable and necessary. Our physician reviewer found the enrollee has been evaluated by Neurology and diagnosed with neuritis. An MRI of the brain has been approved. A cervical MRI is indicated if unequivocal findings identify specific nerve compromise on the neurologic examination, in patients who do not respond to conservative treatment, and who would consider surgical intervention. Cervical MRI is the mainstay in the evaluation of myelopathy. A cervical MRI should be reserved for patients who have clear-cut neurologic findings and those suspected of ligamentous instability. Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology. In this case the neurological exam is normal. There is no specific clinical rationale for the requested MRI of the neck. 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 MRI of the neck have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provideadditional routine transport trips (A0120).You askedthe Plan to provideadditional transport trips. You say that the additional transport trips are medically necessary.The Plan denied your request. The Plan says the benefit has been exhausted.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to provideadditional routine transport trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgical removal of residual tooth roots for teeth #6 and 20-28 (D7250).You asked the Plan to pre-approvesurgical removal of residual tooth roots for teeth #6 and 20-28. You say that the services are necessary because you are in pain and are unable to eat properly.The Plan denied your request. The Plan says the covered benefit has been exhausted.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. ThePlan covers 2 non-surgical or surgical extractions per calendar year.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of surgical removal of residual tooth roots for teeth #6 and 20-28 have not been met. The plan covers 2 non-surgical or surgical extractions per calendar year. The record shows that you had surgical removal of residual tooth roots for teeth #18 and 19 on June 23, 2020. This means that you are not eligible for coverage of non-surgical or surgical extractions at this time.Therefore, we decided that the Plan does not have to pre-approvesurgical removal of residual tooth roots for teeth #6 and 20-28 (D7250).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306).
You asked the Plan to pre-approve a TTE. You say that the service is necessary. The Plan denied your request.
The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that echocardiography is covered when specific criteria is
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 a TTE. Our reviewer says that the
service is not medically necessary. Our physician reviewer found based on the records the enrollee has no
documented cardiac symptoms and mild-to-moderate valve disease on recent echocardiogram less than 6
months ago. In this circumstance the records do not support the medical necessity for a repeat echocardiogram
at this time. For moderate valve disease a follow up echocardiogram no more than annually is recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 30-74 minutes if critical care services (99291) provided on January 27, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 30-74 minutes of critical care services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the first 30-74 minutes if critical care services (99291) provided on January 27, 2020.