Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional 6 physical therapy (PT) visits.  You asked the Plan to pre-approve an additional 6 PT visits. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the requested services 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 an additional 6 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been approved additional visits already which can ensure competence in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  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 additional 6 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 6 physical therapy (PT) visits.
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 these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are 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. You appear to be unstable and require additional short-term acute care hospital services that can safely be administered at the current facility for the time being. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network
(OON) provider on October 7, 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 service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on October 7,
2021.
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 meets LTACH guidelines and is precluded from a lower level of care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 is receiving appropriate care at the present acute care hospital. 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 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: 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 LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH services have not been met.  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 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 record indicates that the enrollee is improving but still requires ongoing acute care services. 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 the enrollee is not currently receiving but that would be available at the LTACH 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 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 pay for laboratory services provided to the enrollee on March 22, 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 screening FISH testing is not a Medicare benefit for the diagnosis listed on the claim, and is done for the screening purposes.  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 Urovysion testing is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing.  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 laboratory services provided to the enrollee on March 22, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pre-approve 1 additional epidural steroid injection. We decided that the Plan does not have to pre-approve the 2nd additional epidural steroid injection.   You asked the Plan to pre-approve 2 additional epidural steroid injections. You say that the requested services are a necessity for your care because you cannot attempt the requested exercise due to spinal problems. The Plan says that medical necessity rules for the requested services have not been met.  We decided that the Plan has to pre-approve 1 additional epidural steroid injection. We also decided that the Plan does not have to pre-approve the 2nd additional epidural steroid injection.  The Plan follows Medicare rules. The rules say that epidural steroid injection is medically reasonable and necessary when the requirements listed in the Medicare rules section have been met.  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 2 additional epidural steroid injections. Our reviewer says that coverage criteria for the requested services have been partially met. Our physician reviewer found that only one interlaminar epidural steroid injection is medically reasonable and necessary and is compatible with the Medicare rules. A second separate injection is NOT medically reasonable or necessary. The injectate volume can be increased to cover more levels, removing the need for a second injection.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 additional epidural steroid injection have been met. Therefore, we decided that the Plan has to pre-approve 1 additional epidural steroid injection. However, Medicare rules for coverage of the 2nd additional epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the 2nd additional epidural steroid injection.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on August 9, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this is not a Medicare benefit for screening purposes.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the diagnosis is unspecified urinary tract infection. The record provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on August 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee on June 3, 2021.  You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate type of bill.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, these services were not submitted with a correct type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on June 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response without transportation services (A0998) provided on July 9, 2021.  You asked the Plan to pay for the ambulance response without transportation. You say that you would like reconsideration because you were experiencing extreme pain and called an ambulance. You do not feel you should be responsible for the cost. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit, and without a transport there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 9, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response without transportation services (A0998) provided on July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 1, 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 services were not urgent, emergent, or 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 laboratory services provided to the enrollee on February 1, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for laboratory services provided to the enrollee on May 13, 2021.  You asked the Plan to pay for the services. You say that the physician used prudent decision-making. The Plan denied your request. The Plan says that there are no office visit notes provided for review or previous lab testing.  The Plan must follow Medicare rules. Medicare rules say that biomarkers for oncology are covered if the test has proven clinical utility, and has been proven to be able to assist in medical management 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found when thyroid nodule fine-needle aspiration (FNA) cytologic results show follicular lesion of undetermined significance or atypia of undetermined significance (FLUS/AUS, Bethesda III) or follicular neoplasm (Bethesda IV), the results are often called indeterminate. The risk of malignancy with these cytologic classifications ranges from 10 to 40 percent. The Afirma test allows differentiation of benign versus malignant lesions, and if benign, avoidance of surgery. The test has become as standard of care for indeterminate lesions. The service was reasonable and 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 been met. Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on May 13, 2021.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the epidural steroid injection rendered on October 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that an epidural steroid injection is covered when specific criteria are met.  We looked at the file and Medicare rules. There is no documentation to support that the criteria for coverage of the services are met. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the epidural steroid injection rendered on October 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378).

You asked the Plan to pre-approve a diagnostic colonoscopy. The Plan denied your request. The Plan says a
diagnostic colonoscopy is not medically necessary due to the low risk profile coupled with benign pathology on
a single polyp from 2016 and the US Multi-Society Task Force document.

The Plan follows Medicare rules.

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 diagnostic colonoscopy. Our reviewer
says that the colonoscopy is not medically necessary. Our physician reviewer found that the enrollee is a 67
year old female with history of celiac disease and most recent colonoscopy on May 13, 2016. A 5 mm polyp
was noted in the sigmoid colon and pathology showed polypoid colonic mucosa containing lymphoid aggregate
with no malignancy identified. Per the guidelines, the benign pathology of the single isolated sigmoid polyp
would warrant follow up at the 10-year mark, 2026. In addition, documentation reviewed does not show the
member at high risk for colon cancer. Given this low risk profile, coupled with the benign pathology on the
single isolated polyp in 2016, the review has determined that the requested colonoscopy does not meet the
Medicare LCD L34614 coverage criteria.

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 diagnostic colonoscopy have not been met. Therefore, we decided that the
Plan does not have to pre-approve a diagnostic colonoscopy (45378).
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 are receiving therapy and acute rehabilitation is recommended. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 IRF admission is not medically necessary based on lack of medical complexity, rehabilitation nursing needs, and your high functional level. While you may benefit from physical therapy and occupational therapy, your care needs can be safely met in an alternate and lower intensity setting such as a skilled nursing facility or home health 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.