Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe liver transplant services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON transplant services. You say that you have been receiving care from this facility and feel that you should not be required to switch.The Plan denied your request. The Plan says there is no medical reason that transfer to a network provider is not medically reasonable after a single transitional visit.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 provider at issue in this case is not a network provider with the Plan. 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 OON transplant services. Our reviewer says that the requested OON care is not shown to be medically reasonable and necessary. Our physician reviewer found the enrollee is a male with cirrhosis, most recent MELD score is 18 and creatinine of 2.0. The patient may need liver transplant in the future, but has not been listed on the transplant list. There is no compelling reason to allow OON care when in-network provider and services are available. One transitional visit is medically necessary to allow for appropriate transfer.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 OON transplant services have not been met. 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 the OON transplant services.Therefore, we decided that the Plan does not have to pre-approvethe liver transplant services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the self-administered drugs provided from November 1, 2019 to November 2, 2019. You asked the Plan to pre-approve these drugs. The Plan denied your request. The Plan says that this is not covered under Part B. 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 Plan does not have to pre-approve the self-administered drugs provided from November 1, 2019 to November 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) and ankle foot orthosis (L1971) provided on June 24, 2019.
You asked the Plan to pay for lumbar sacral orthosis (L0650) and ankle foot orthosis (L1971). You say that you would like reconsideration as this DME is medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) and ankle foot orthosis (L1971) provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for fundus photography (92280) provided on August 15, 2019.You asked the Plan to pay for the fundus photography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the specialty of the servicing provider on the submitted claim is Family Medicine and is ineligible for payment.The Plan must follow Medicare rules. Medicare rules say that payment is made for the use of this procedure by an opthalmologist in these situations when it is reasonable and necessary for the individual patient to receive these services.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the fundus photography have not been met. Specifically, the record indicates that the rendering provider specializes in Family Medicine. This is not a valid specialty for Medicare payment of this service. Therefore, we decided that the Plan does not have to pay for fundus photography (92280) provided on August 15, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 0.75mg/0.5ml Trulicity pen (C9399).You asked the Plan to pre-approve the Trulicity pen. You say that this drug is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says Trulicity has been determined to be usually self-administered by the patients and therefore not eligible for Medicare Part B 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 Plan does not have to pre-approve a 0.75mg/0.5ml Trulicity pen (C9399). Benefits for the Trulicity pen may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) angiography of the heart (75574).You asked the Plan to pre-approvea CT angiography of the heart. You say that the service is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 wascorrect in denying the request to pre-approve a CT angiography of the heart. Our reviewer says that the service is not medically necessary. Our physician reviewer found a CT coronary angiogram has been requested but denied absent medical necessity. The criteria for coronary angiogramCT require that the enrolleebe symptomatic concerning likely coronary disease. The elevated coronary calcium score is not a clinical symptom but does reflect atherosclerotic disease of significance within the coronary vessels. Incidentally, the markedly elevated coronary calcium score of greater than 3000 likely would be a limiting factor if CT were to be done due to the dense calcifications likely within all coronary vessels.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 CT angiography of the heart have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomographic (CT) angiography of the heart (75574).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
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's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. He is receiving skilled nursing facility (SNF) level of care and does not require medical oversight of his condition at an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. He is unable to perform essential activities of daily living without assistance. The enrollee is limited by pain after his recent fall and surgery. There are limited goals due to his orthopedic status, which is not expected to change in the short-term period of time. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. An intensive rehabilitation therapy program would not significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility level.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is receiving appropriateinpatient acute care, and does not require transfer to the LTACH.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 isnot considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for pulmonary fibrosis. 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 carefor 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on July 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a mammogram. You say that the enrollee had this procedure one year ago, at the same location and the insurance covered it. The Plan denied your request. The Plan says no prior authorization was obtained of these services.
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 a mammogram provided on July 23, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbosacral facet injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the degree of pain relief does not meet the LCD criteria. The last set of injection was described as 50% pain relief, and no relief of low back pain. The request is deemed not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbosacral facet injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the member meets IRF admission criteria and is stable to transfer. The Plan denied your request. The Plan says the member can safely receive the necessary services in other settings.
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 the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member is not expected to make a significant functional improvement in the predicted period of time in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/18/20 with intractable seizure, obtunded state and blood sugar greater than 500. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including tracheostomy care, surveillance laboratory studies, transfusions as indicated, tube feeding, and therapy services. 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 he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the transportation services were medically necessary for the enrollee and should be processed accordingly by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a uvulectomy (42140).
You asked the Plan to pre-approve a uvulectomy (42140). You say that the requested uvulectomy is medically
necessary. The Plan denied your request. The Plan says the requested uvulectomy is not medically necessary.
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 a uvulectomy (42140). Our reviewer
says that the requested uvulectomy is not medically necessary. Our physician reviewer found the enrollee is
with other lesions of oral mucosa (uvula hypertrophy), and snoring. The enrollee's symptoms include a globus
sensation, chronic cough, nasal obstruction, and postnasal drainage. The uvula is long, and sits on the superior
1/4 of the epiglottis. The provider in this case, an otolaryngologist, documents that a partial uvulectomy may
improve the enrollee's symptoms. A uvulectomy may be recommended when the uvula is large and interferes
with sleep or breathing. It is not clear that a uvulectomy is medically reasonable and necessary 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 a uvulectomy (42140) have not been met. Therefore, we decided that the Plan
does not have to pre-approve a uvulectomy (42140).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiography (93307).You asked the Plan to pre-approvea transthoracic echocardiography (93307). You say that the requested transthoracic echocardiography is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested transthoracic echocardiography.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 a transthoracic echocardiography (93307). Our reviewer says that the enrollee does not meet criteria for the requested transthoracic echocardiography. Our physician reviewer found the enrollee is with a history of hypertension, diabetes, obesity, and coronary artery disease including remote coronary angioplasty and myocardial infarction. A clinic noted dated 03/02/2020 documents inactivity, no cardiac symptoms, and unchanged murmur on exam and a scheduled surgical parotidectomy under general anesthesia. An echocardiogram 02/12/2014 reported aortic valve sclerosis, LV hypertrophy, inferolateral hypokinesis and LV ejection fraction of 50%. An 
electrocardiogram reported NSR with RBBB/LAFB and NSSTT changes and is unchanged from 2017.Based on the records the enrollee has known coronary disease but no current cardiac symptoms, no change on cardiac physical exam or electrocardiogram, no significant valve disease on echocardiography and scheduled for lower risk non-cardiac surgery. In this circumstance of a stable patient schedule to have a non-high risk non-cardiac surgery, the records do not support the medical necessity for a repeat echocardiogram. Current guidelines also do not consider preoperative echocardiography appropriate in this 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 a transthoracic echocardiography (93307) have not been met.Therefore, we decided that the Plan does not have to pre-approvea transthoracic echocardiography (93307).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120 x 2), prophylaxis (D1110 x 2), and the bitewing x-rays (D0274) provided from April 18, 2019 to October 24, 2019.
You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for years. You also say that the dentist is good and takes excellent care of your teeth. The Plan denied your request. The Plan says dental services that you receive out of network are not covered.
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 dental services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120 x 2), prophylaxis (D1110 x 2), and the bitewing x-rays (D0274) provided from April 18, 2019 to October 24, 2019.