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

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care.. You say that the records provided support that inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says the medical records do not support the need for continued inpatient psychiatric care. The Plan says that the enrollee could receive care safely in a different setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on January 06, 2022, with Schizoaffective Disorder Bipolar Type, Impulse Disorder Unspecified and Autism Spectrum. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The patient was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care. have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Foresee home monitoring system (CPT code 0379T), for the enrollee.
You asked the Plan to pre-approve the service. You say that this service is necessary. The Plan denied your request. The Plan says there is insufficient evidence to support the medical necessity and has not been shown to improve the health outcome.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has non-exudative macular degeneration. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve Foresee home monitoring system (CPT code 0379T), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for the laboratory services
provided on July 20, 2021.
You asked the Plan to waive the deductible and copayment for the laboratory services. You say that you paid
less money the year prior for the same services. The Plan denied your request. The Plan says the appropriate
deductible and copayment was applied.
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 $300
deductible before the Plan will pay their share for enrollees covered medical services and then you will pay
your share of copayments or coinsurances amounts for the rest of the calendar year from an in-network
providers. Prior to the date of service, a total amount of $59.06 was paid towards the $300 deductible. Which
left a balance of $240.94 ($300 deductible - $59.06 deductible balance).
Your contract with the Plan also clearly says that you must pay a $10 copayment for Medicare-covered lab
services.
You have been asked to pay a $240.94 deductible and a $10 copayment for the laboratory services. The
deductible falls within the What is your plan deductible benefit category. While the laboratory services fall
within the Outpatient diagnostic tests and therapeutic services and supplies 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 deductible and copayment for the laboratory services provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin graft services.
You asked the Plan to pre-approve skin graft services. You say that these services are 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 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 skin graft services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the patient is a 75-year-old female who has a lower extremity wound on the
ankle measuring 0.9 x 0.9 x 0.3 centimeters (cm) and treated with debridement, Medihoney, antibiotics, and
daily dressing changes. Recent documentation describes the wound as being 0.7 x 0.6 x 0.3 cm after
conservative treatment for 30 days. The provided documentation does not show that the patient had a chronic
wound that had failed standard treatment for a reasonable amount of time in order to justify grafting at this
time. The wound appears to be improving with treatment. Therefore, the request for grafting services will be
considered 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 skin graft services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skin graft services
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the ultraviolet (UV) light therapy system, includes bulbs/lamps,
timer and eye protection; treatment area 2 square feet or less (CPT code E0691), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee's psoriasis and vitilago would benefit
from UVB phototherapy as the enrollee is unable to make the trip to the clinic for twice weekly UVB therapy.
The Plan denied your request. The Plan says that there is no supporting documentation stating what type of
psoriasis the enrollee has. The Plan states there is no supporting documentation indicating if there has been an
appropriate consultation that has determined that the enrollee has a medical condition or other factors that
justify the medical necessity for the treatment in the home rather than other alternative sites (e.g., outpatient
department of a hospital, etc.).
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found it is stated that "The member has a history of frequent flaring which requires immediate
treatment to control the disease. The member areas of involvement include: the scalp, occiput, elbow and
gluteal cleft area. The member has tried betamethasone, clobetasol, ketoconazole shampoo, and salicylic acid
shampoo. The member is unable to utilize in-clinic phototherapy due to frequency required and very lengthy
travel." So, the enrollee has failed two (2) topical corticosteroids. Therefore, the medical records provided meet
the requirements listed in the NCD for Medicare coverage.
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 been met. Therefore, we decided that the Plan has to pre-
approve the ultraviolet (UV) light therapy system, includes bulbs/lamps, timer and eye protection; treatment
area 2 square feet or less (CPT code E0691), for the enrollee.
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: 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 does not meet criteria.  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 you appear to be improving and require only short-term additional acute care services that can be safely administered at the current facility for now. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.    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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT code 81162).  You asked the Plan to pre-approve the testing. You say that the service is necessary. The Plan denied your request. The Plan says Medicare doesn't cover BRCA genetic testing for breast cancer risk if you do not have a personal history of breast, ovarian, or pancreatic cancer. The Plan states it is considered to be screening and is specifically excluded by Medicare.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT code 81162).
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 suffered a stroke and became very sick while hospitalized. You say that you cannot eat solid foods, walk on your own, get in and out of bed, go to the bathroom alone, or take care of yourself. You say that you need focused rehabilitation to get stronger, relearn how to walk, and to be able to function on your own. The Plan denied your request. The Plan says the records show that the enrollee's current medical and rehabilitation needs are no of the intensity and complexity that would require rehabilitation therapies for 3 hours per day at least five days per week in a hospital 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 there are no acute or complex rehabilitation nursing needs noted in the record. The enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee's rehabilitation needs can be met at a lower intensity setting. An IRF admission is not medically necessary based on lack of medical complexity and rehabilitation nursing needs. The enrollee's rehabilitation needs can safely be met at an alternate and lower intensity setting such as a skilled nursing facility.  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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on September 28, 2021.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the telehealth service was rendered by an out of network provider, therefore it is not a covered benefit.  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 service provided in this case was a telehealth office visit. The Plan contract states that a telehealth visit is only covered when rendered by a network provider. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on September 28, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthotic device.
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the records provided demonstrate
that the enrollee has exhausted other available therapies and has not regained meaningful use of his right
dominant upper extremity. You say that without further intervention the enrollee will labor indefinitely with his
disability. The Plan denied your request. The Plan says medical studies haven't proven that the requested device
is helpful for treatment of the enrollee's health problem.
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 MyoPro orthotic device. Our reviewer
says that a MyoPro orthotic device is not considered medically reasonable and necessary in this case. Our
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in
widespread use based on scientific evidence.
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes
for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence
in the literature that this device will increase participation in bimanual activities.
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 MyoPro orthotic device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an electric breast pump (E0603) provided on July 27, 2021.
You asked the Plan to pay for an electric breast pump. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue was used in the absence of illness or injury.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for an electric breast pump (E0603) provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870) and interspinous process distraction device (C1821).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870) and interspinous process distraction device (C1821). You say that the member has failed conservative approaches to treatment including physical therapy, medications, injections and various non-sustainable treatments. You say that the procedure is medically necessary and should be approved. The Plan denied your request. The Plan says the services are 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 insertion of stabilization device (22869 and 22870) and interspinous process distraction device (C1821). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has multi-level degenerative disease with mild foraminal stenosis, the enrollee has had a previous L5-S1 fusion, and that flexion worsens the pain. Our reviewer says that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of stabilization device (22869 and 22870) and interspinous process distraction device (C1821) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870) and interspinous process distraction device (C1821).
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 does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving but not yet stable. The enrollee requires only short-term additional acute care services for stable feeding that can be safely administered at the current facility for now. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), and prophylaxis (D1110) provided
on August 23, 2021.
You asked the Plan to pay for the dental services. You say that you were not advised of the provider's network
status. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan
says the provider in this case is out of network. The Plan also says dental services 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 pay for the oral exam (D0120), and prophylaxis (D1110)
provided on August 23, 2021.