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

We decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
You asked the Plan to pre-approve 5 additional home health visits. You say that the enrollee is currently in a waist brace. You say that the enrollee is having difficulty walking with a walker. You also say that the enrollee is still recovering from a previous fall. The Plan denied your request. The Plan says the requested additional visits are not medically reasonable or 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 5 additional home health visits. Our reviewer says that 5 additional home health visits are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration for the five denied visits. The reviewer found that the provided documentation indicates that the enrollee appears to have had improvement in her gait with therapy but then suffered a fall. The documentation shows that the enrollee had received a total of 23 home health physical therapy sessions approved thus far. The reviewer also found that there is no information in the provided records to clarify why the additional 5 physical therapy visits that have been approved are inadequate to treat the enrollee's condition and transition to a home exercise program. Therefore, the reviewer found that the additional visits are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional home health visits have not been met. The record does not indicate that the 5 additional visits that were approved are inadequate to treat the enrollee's condition and transition to a home exercise program. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans, X-rays and ultrasounds provided from February 15, 2021, to April 19, 2021.
You asked the Plan to waive the copayments for CT scans, X-rays and ultrasounds. You say that you disagree with the increase in charges from last year and feel that they are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $160 copayment for radiological diagnostic services. Your contract with the Plan also clearly says that you must pay
a $15 copayment for X-rays. You received CT scans, X-rays and ultrasounds from February 15, 2021, to April 19, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service Code
Allowed Amount
Amount You Owe
2/15/2021
74178
$361.10
$160
3/16/2021
71046
$279
$15
3/16/2021
71275
$174.14
$160
3/18/2021
93880
$225.74
$160
4/2/2021
74018
$79.36
$15
4/19/2021
93306
$313.68
$160
The total amount you owe is: $670. You have been asked to pay the total copayment amount of $670 for CT scans, X-rays and ultrasounds. CT scans, X-rays and ultrasounds 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 copayments for CT scans, X-rays and ultrasounds provided from February 15, 2021, to April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the leadless pacemaker, for the enrollee.

You asked the Plan to pre-approve the leadless pacemaker. You say that the enrollee needs a V node ablation. You state the enrollee is failing atrial fibrillation treatments, has undergone Atrial fibrillation ablations, failed multiple medications including Amiodorone. You state there are no other options lefts. The Plan denied your request. The Plan says the records we received do not show that the enrollee is enrolled in an FDA approved study. The Plan states in order for the requested services to be covered, the enrollee would need to have clinical notes that show the enrollee is enrolled and participating in a clinical study, along with the identification number for the CMS approval of the study.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the leadless pacemaker have not been met. Your records do not show enrollment in a clinical study. Therefore, we decided that the Plan does not have to pre-approve the leadless pacemaker, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left atrial appendage closure.

You asked the Plan to pre-approve left atrial appendage closure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that LAAC is only covered for certain 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 left atrial appendage closure. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found although the enrollee has an elevated CHA2DS2VASc score, the enrollee has no active bleeding issues currently on anti-coagulation therapy. The enrollee has had several falls however and is therefore being considered for the Watchman device. CMS requirements for consideration of placement of the Watchman device include shared decision making using an evidence based bleeding tool with a non-interventional, independent, non-implanting physician as well as follow-up in an ongoing CMS approved registry of the device. Based on the clinical information provided there is no documentation that either of these criteria have been met as the notes provided are from the implanting physician only and there is no documentation of a shared decision making discussion with a non implanting physician or use of an evidence based tool for bleeding risk (HASBLED, etc). In addition, there is no documentation of an audited CMS approved follow-up registry at the implanting center. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left atrial appendage closure have not been met. Therefore, we decided that the Plan does not have to pre-approve left atrial appendage closure.
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 no longer needs to be in the hospital. However, she does need more care than is going to be found at a lower-level facility because of comorbidity. The Plan denied your request. The Plan says that criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting.

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 the enrollee remains ventilated and has had severe neurologic injury. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertiflex superion device.

You asked the Plan to pre-approve vertiflex superion device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 vertiflex superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain and leg pain with neurogenic claudation. The vertiflex device is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertiflex superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve vertiflex superion device.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says as acute care hospitals and LTACHs are licensed to provide the same level of care, there is no advantage in moving the enrollee from the current acute care hospital 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 the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve Vertiflex. You say that this procedure would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this is helpful for treatment of the enrollee's condition.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show the safety and efficacy of this 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with CPT codes 87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532 and 87631 on May 11, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory Place of Service code but the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with CPT codes 87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532 and 87631 on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) office consultations and treatment (CPT code
99214) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visits. You say that this clinic will provide the help and relief you
need. The Plan denied your request. The Plan says this provider is not in-network and there are in-network
providers that can provide the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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
six (6) office consultations and treatment (CPT code 99214) to be provided by an out-of-network provider.
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 are receiving appropriate care at the present acute care hospital. There are no
services available at the LTACH that you require that are not available at the health care setting being offered
by the health plan.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you were advised that the enrollee was private pay, and the SNF never verified if there was insurance. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.

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 admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits.

You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because the additional therapy is medically necessary. The Plan denied your request. The Plan says the records do not show that further physical therapy will help maintain or improve function.

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 additional physical therapy. Our
reviewer says that the enrollee does not have documented skilled therapy needs. Our physician reviewer found
the enrollee is functioning at a level commiserate with a lower level of care such as a home exercise program.

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 additional physical therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve 6 additional home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery.

You asked the Plan to pre-approve the surgical services. You say that your test results fall within the normal range of a non-smoker. The Plan denied your request. The Plan says the spinal fusion surgery is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgical services. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee is currently a smoker. The reviewer found that smoking is a contraindication to fusion surgery. Therefore, the reviewer found that the requested surgery is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Specifically, smoking is a contraindication to fusion surgery.

Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery.