Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health physical therapy visits.
You asked the Plan to pre-approve the requested services. You say that you cannot use a cane by yourself. The Plan denied your request. The Plan says this level of care is no longer 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 requested services. Our physician reviewer found that you are at a supervision assist level for transfers, supervision for walking using a wheeled walker, and standby assist for step-ups. You do not have documented ongoing home health physical therapy needs. You are functioning at a level consistent with a lower level of care. Therefore, the requested services are not medically necessary or reasonable. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
June 15, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 out of network physician services provided to the
enrollee on June 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that due to the Coronavirus you do not want to be on a bus with other people, and you do not have a car. You also say that the rides were more convenient for you. The Plan denied your request. The Plan says you have exhausted your 24 one-way transportation trips benefit for the 2021 plan year. The Plan also says that additional trips cannot be added.
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 up to 24 one-way 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 pre-approve additional non-emergency transportation (A0100).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test.
You asked the Plan to pre-approve an OmniSeq Insight Panel test. You say that the requested test is medically necessary and was ordered to assist in determining the most appropriate treatment pathway. The Plan denied your request. The Plan says the requested testing is not medically necessary as it is unlikely to impact therapeutic decision making.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that molecular pathology procedures are eligible for coverage when the results of the testing directly impact treatment or management of the Medicare beneficiary. 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 an OmniSeq Insight Panel test. Our reviewer says that an OmniSeq Insight Panel test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of stage IV breast cancer metastatic to bone.
The enrollee was recently diagnosed with gastric adenocarcinoma. A gastric wall biopsy on September 3, 2021, revealed poorly differentiated invasive adenocarcinoma. The enrollee's performance is documented to be poor. The prognosis is likewise poor. The documentation in the case file does not support that the number of genes/tests in the OmniSeq Insight testing panel are medically reasonable and necessary for the enrollee in this case, and that the testing directly impacts the treatment or management of the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OmniSeq Insight Panel test have not been met. Therefore, we decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.

You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 an intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for low back pain. More research is needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 pre-approve skilled nursing facility (SNF) services.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 an alternate level of 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.

You asked the Plan to pre-approve BRCA testing. You say that there is a history of prostate cancer in your
family. The Plan denied your request. The Plan says the denial of authorization for this testing is correct,
because this testing is considered to be screening and is specifically excluded by Medicare.

The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is non-covered
for testing of individuals with no personal history of specified cancers.

We looked at the file and Medicare rules. The record shows that this testing is being requested with no personal
history of cancer. Therefore, it is considered screening. Based on this information, we decided that Medicare
rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to
pre-approve BRCA genetic testing.
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 you need IRF care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can receive the necessary care in an alternate setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) brain (78608).

You asked the Plan to pre-approve the PET scan. You say that the PET scan is ordered to rule out
frontotemporal dementia vs. Alzheimer's disease. The Plan denied your request. The Plan says the requested
service is not medically necessary and repeat imaging is not supported.

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 PET scan. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee is a 77 female diagnosed memory loss presumed to be due to vitamin B12
deficiency and meningioma. It was documented that her attention is poor. Documentation does not support
dementia as only poor memory was noted. Based on the provided documentation, there was insufficient
evidence for Alzheimer's dementia or frontotemporal dementia or other condition to justify FDG PET scan.

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 PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve positron emission tomography (PET) brain (78608).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 28, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that you disagree with the Plan's denial. The
Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency
limit of one every 12 months.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded
the frequency limit prior to this service on March 8, 2021. Therefore, we decided that the Plan does not have to
pay for a limited oral evaluation (D0140) provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergent transportation trips.
You asked the Plan to pre-approve additional non-emergent transportation trips. You say that you have exhausted the 6 rides your plan covers and you need to utilize this service. You say that you use an electric wheelchair and cannot afford the charges in addition to copayments. The Plan denied your request. The Plan says additional trips cannot be provided.
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 6 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 pre-approve additional non-emergent transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 there is no documentation that the enrollee
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This
enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified
therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily
skilled services are not required. Therapy 3-5 times per week is recommended in the provided records. This
enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in the home with
home health care or in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (CPT code E2363) and power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds (CPT code K0813), for the enrollee.
You asked the Plan to pre-approve the DME. You say that you have carefully examined the enrollee's medical conditions and you have determined the enrollee would benefit from a motorized scooter. The Plan denied your request. The Plan says they do not have information about the enrollee's functional mobility evaluation and home evaluation.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 DME. Our physician reviewer found there is documentation of a gait abnormality with prior stroke and hemiparesis but the records do not document that this enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Based on the medical records provided, there is no documentation that the enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. There is no documentation that the enrollee can safely operate a power mobility device. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (CPT code E2363) and power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds (CPT code K0813), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for radiology services provided on December 21, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says insufficient medical records were submitted to support the services billed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Insufficient medical records were submitted for review of this claim. Therefore, we decided that the Plan does not have to pay for radiology services provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a general
surgeon on June 16, 2021.
You asked the Plan to waive the copayment for the surgery office visit. You say that you went to this doctor
because you had a spot on your leg that needed to be removed. You said the doctor looked at it and said that the
procedure needed to be rescheduled because the office was short-staffed. You said that no one ever called you
back to reschedule, so you don't think you should have to pay this copayment. The Plan denied your request.
The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for visits with a specialist.
You have been asked to pay a $40 copayment for the surgery office visit. The medical records from this visit
show that your skin lesion was evaluated, and you discussed an excision procedure with the doctor. You were
advised that a procedure would be scheduled in the near future and surgery risks were reviewed with you. The
office visit copayment applies regardless of the extent of services you receive. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the office visit you had with a general surgeon on June 16, 2021.