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 enrollee requires an LTACH 
admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an 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 is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for the 
requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: 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 enrollee will greatly benefit from IRF care to regain her strength to her previous level of function. The Plan denied your request. The Plan says under Medicare, your request is not medically necessary.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants (D6010) for teeth 21, 28, 29, and 31 provided by a participating provider.
You asked the Plan to pre-approve endosteal implants. You say that the enrollee feels pain and cannot eat. The Plan denied your request. The Plan says there may be other treatment options for your dentist to replace your missing teeth, such as a partial denture.
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 pre-approve endosteal implants (D6010) for teeth 21, 28, 29, and 31 provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgeries (D4260) and bone replacement grafts (D4263 and D4264).

You asked the Plan to pre-approve the osseous surgeries and bone replacement grafts. The Plan denied your request. The Plan says these services are not covered under your benefit package.

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 pre-approve osseous surgeries (D4260) and bone replacement grafts (D4263 and D4264).
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 your condition will continue to decline without IRF care, and these services are medically necessary for your safe return home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only under certain medical indications.
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 wheelchair. Our physician reviewer found that the documentation does reveal a mobility deficit, but the documentation does not reveal your mobility deficit is due to a neurological condition, a myopathy, or a congenital skeletal deformity. The documentation states that you have left arm weakness from a stroke. The documentation does not support that your gait dysfunction is from one of the qualifying Group 3 diagnosis. Furthermore, the documentation is inconsistent on your ambulatory function. The physician's note states that you have abnormal gait and cannot take more than 2 steps unassisted, yet the same note states that you take your dog for a walk daily. The records show that you are walking as much as you can, and you do not want formal therapy. Based on the review of the records, the requested wheelchair 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 the requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81292) provided on March 23, 2021.
You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a
single procedural service, so 1 code must be submitted for the panel. We find that CPT codes 81206 and 81292 are not supported in the medical record. Specifically, this codes were used to report a panel, which should be billed with one code. Based on this information, we decided that Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus gene panel (81206, 81292) provided on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 states the enrollee's needs can be safely met at an alternate, less intensive level of care. The Plan states based on the enrollee's current needs they suggest care in a skilled nursing facility or at home with home health 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a fall, congestive heart failure, and kidney insufficiency. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 this enrollee 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that the patient reports 40% improvement with left knee pain. You say that functional limitations include difficulty going downstairs and has not attempted jogging or playing tennis. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 8 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are
not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and management services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON evaluation and management services. You say that the enrollee 
has cancer and is unable to perform daily activities. You say that the enrollee's health is declining and the 
services being requested are medically necessary. The Plan denied your request. The Plan says there are 
network providers within a reasonable distance of the enrollee's location that can provide the services being 
requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
evaluation and management services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pacemaker implant procedure for the enrollee to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you would like to have this done at a low risk setting facility. The Plan denied your request. The Plan says that the requested service is available at a network facility.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pacemaker implant procedure for the enrollee to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, upper extremity; without contrast material, followed by contrast material(s) and further sections -right (CPT code 73202), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says one on CPT code 73202 is approved and the other is denied as a duplicate.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. The Plan approved one CPT code 73202 and the other CT scan is denied as a duplicate. Therefore, we decided that the Plan does not have to pre-approve CT scan, upper extremity; without contrast material, followed by contrast material(s) and further sections -right (CPT code 73202), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan has to pre-approve CT scan of the heart. 
 
You asked the Plan to pre-approve the scan. You say that this is needed to screen for disease in the heart. The 
Plan denied your request. The Plan says that this denial is appropriate given the clinical scenario. 
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found you are at increased risk 
for coronary heart disease, given the hypertension and hyperlipidemia. Together with the recent onset of 
dyspnea on exertion the possibility of coronary related insufficiency must be entertained. The requested CT 
calcium scoring thus is a useful tool for risk stratification and thus would be covered per CMS guidelines. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the heart.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sterile foam wound dressings (A6212) provided on July 23, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound dressings. You say that the services should be a covered benefit with 
the enrollee's plan. The Plan denied your request. The Plan says these services are not urgent or emergent, nor 
were they approved in advance. 
 
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 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 sterile foam wound dressings (A6212) provided on 
July 23, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for future radiation therapy visits.
You asked the Plan to waive the copayments for future radiation therapy visits. You say that you will not be able to afford these copayments. The Plan denied your request. The Plan says these copayments will apply each time you receive these services.
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 $60 copayment per visit for radiation therapy. You have been asked to pay a $60 copayment per visit for future radiation therapy visits. 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 copayments for future radiation therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear medicine study of lung 
ventilation you had on July 1, 2021. 
 
You asked the Plan to waive the copayment for the nuclear study. You say that you were not aware of this 
copayment.  You stated that you are on a fixed income and if you were aware of the copayment, you would not 
have had the service. 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 $250 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $250 copayment for the nuclear study. The nuclear study falls within the 
diagnostic radiology services benefit category. 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 nuclear 
medicine study of lung ventilation you had on July 1, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) procedure you had on May 12, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you do not understand why if you are having two procedures at the same time in the same room, why you you being charged a copayment for the endoscopy. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not charged for the colonoscopy you had at the same time because that service doesn't have a copayment.
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 $75 copayment for endoscopies.
You have been asked to pay a $75 copayment for the EGD. The EGD falls within the endoscopies benefit category. 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 esophagogastroduodenoscopy (EGD) procedure you had on May 12, 2021.