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

We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on June 7, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found based on the medical records, provided there is no documentation that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health on June 07, 2021. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided to the enrollee on June 7, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan you had on April 20, 2021, and the endoscopy-cystoscopy procedure you had on April 28, 2021, at an out-of-network provider.
You asked the Plan to waive the cost sharing for the out-of-network CT scan and endoscopy-cystoscopy procedure. You say that you were given contradictory information about out-of-network care, so these claims should be paid. The Plan denied your request. The Plan says you were charged this cost sharing 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 $350 copayment for CT scans. There is also a $1,000 deductible that applies to outpatient surgery.
You have been asked to pay a $350 copayment for the CT scan and a $1000 deductible for the endoscopy-cystoscopy procedure. 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 cost sharing for the computed tomography (CT) scan you had on April 20, 2021, and the endoscopy-cystoscopy procedure you had on April 28, 2021, at an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure code 36556) provided to the enrollee on May 24, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is an invalid or missing modifier.
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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, modifier 51 is inappropriate to report. The Multiple Surgery indicator for code 36556 is 0, No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day another procedure, base payment on the lower of the actual charge or the fee schedule amount for the procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 36556) provided to the enrollee on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information submitted by the provider does not demonstrate medical necessity.
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 was correct in denying the request to pre-approve the services. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is mention of ongoing or relapsing pancreatitis but her physical exam is normal and no abnormal lab results have been submitted. No prior imaging results have been entered. Absent such details the medical necessity of CT of the abdomen has not been established. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tablet 30mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit.
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 Otezla tablet 30mg 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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example, a skilled nursing facility, home with home health and home physical therapy.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a head injury after a fall.. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral radiofrequency ablation of the sacroiliac joint (SIJ) provided to the enrollee on June 3, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says experimental or investigational services are not covered.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational.

Studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 services have not been met. Therefore, we decided that the Plan does not have to pay for bilateral radiofrequency ablation of the sacroiliac joint (SIJ) provided to the enrollee on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine procedure.

You asked the Plan to pre-approve a spine procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 a spine 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 is experimental. More research is needed to show safety and efficacy of the procedure. 

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 spine procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a spine procedure.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the heart.

You asked the Plan to pre-approve an MRI of the heart. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

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 an MRI of the heart. Our reviewer says that the services are medically necessary. Our physician reviewer found the gold standard, left heart catheterization is off the table due to the enrollee's chronic renal disease with a Creatinine of 3.5 which precludes iodinated contrast injection. Thus, the next best test will be cardiac MRI which does not require such contrast. Note the evaluation for possible ischemia is a recognized CMS criterion for this test. 

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 MRI of the heart have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (procedure code 97530) provided to the enrollee on May 13, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the code is not appropriate for the services 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 97530 is "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes." 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation supports that an occupational therapist performed the services in the home setting. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for services provided in the home. Therefore, CPT 97530 would not be covered.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (procedure code 97530) provided to the enrollee on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sylvant.
You asked the Plan to pre-approve Sylvant. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Sylvant. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the review indicates that the
documentation did not support that the Sylvant is medically reasonable and necessary for the enrollee. The
documentation did not support that the Sylvant is safe and effective for 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 Sylvant have not been met. Therefore, we decided that the Plan does not have to
pre-approve Sylvant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for
coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.
You asked the Plan to pre-approve Restasis. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Restasis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cleaning (D1110) provided on August 16, 2021.

You asked the Plan to reimburse you for the dental service. You say that you should be reimbursed for this service. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental service received 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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the cleaning (D1110) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions and an evaluation to be performed by
an oral surgeon.
You asked the Plan to pre-approve dental extractions and an evaluation to be performed by an oral surgeon.
You say that the services are necessary. The Plan denied your request. The Plan says based on the
documentation provided, coverage criteria has not been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says covered
services must be performed by a participating general dentist.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of dental extractions and an evaluation to be performed by an oral surgeon have
not been met. Therefore, we decided that the Plan does not have to pre-approve dental extractions and an
evaluation to be performed by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you
had on July 1, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you expected to pay $25, not $150. 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 $150
copayment for diagnostic radiological services.
You have been asked to pay a $150 copayment for the MRI. The MRI falls within the diagnostic radiological
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 magnetic resonance
imaging (MRI) you had on July 1, 2021.