Persius/hicric huggingface dataset:
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 requires inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can safely be met at a lower level of 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 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. 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 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 replacement prosthetic leg with an advanced foot feature.  You asked the Plan to pre-approve prosthetic services. You say that a replacement upgraded prosthetic leg 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 the replacement of a prosthetic limb will be considered based on the criteria listed in the Medicare rules section.  We looked at the file and Medicare rules. In this case, the enrollee received a prosthetic limb in April 2020. There is no indication that the current prosthetic limb has had irreparable damage or requires repairs. In addition, there is no evidence that the enrollee has had a change in condition. Based on this information, we decided that Medicare rules for coverage of prosthetic services have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic leg with an advanced foot feature.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that you are appealing with supporting records The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does not have specific findings to show that Aduhelm criteria are met.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Aduhelm. Our reviewer says that the enrollee does not meet the criteria for the requested use of Aduhelm. Our physician reviewer found Aduhelm is Food & Drug Administration (FDA) approved for the treatment of Alzheimer's disease, and should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, the population in which was initiated in clinical trials. There are no safety or effectiveness data on initiating treatment at earlier or later stages of the disease than were studied. The enrollee in this case is on Memantine, which is indicated for moderate to severe Alzheimer's disease. The FDA-approved label states that Aduhelm is "approved under accelerated approval based on reduction in amyloid beta plaques observed in patients treated with Aduhelm." The case file does not contain documentation of amyloid beta plaques in this enrollee. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Aduhelm.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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 a crown (D2752) and core build up (D2950) for tooth # 30.  You asked the Plan to pre-approve the dental services. You say that a composite restoration will not provide a long term prognosis due to the size and location of the decay. You also say that the services are necessary. The Plan denied your request. The Plan says the crown and core build up are not medically necessary.  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 covers the dental services when the services are medically necessary and reasonable.   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 dental services. Our reviewer says that the requested crown and core build up for tooth # 30 are not medically necessary. Our physician reviewer found the provided documentation indicates there is insufficient missing or damaged tooth structure to require a full coverage restoration for protection. Therefore, the reviewer found that the requested treatment does not appear to be reasonable or medically necessary.  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 the dental services have not been met. Specifically, tooth # 30 does not have significant breakdown that would warrant a crown and core build up. Therefore, we decided that the Plan does not have to pre-approve a crown (D2752) and core build up (D2950) for tooth # 30.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve non-emergency ambulance transport to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says they confirmed with participating provider they the in-network provider can transport the enrollee by means of a stretcher from their residential home site to the dialysis center by ambulance as the enrollee is unable to sit in a wheelchair. The Plan states Windsor EMS, INC, can provide ambulance transport immediately upon approval and is accepting new patients as the Health Plan has confirmed the information.  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 non-emergency ambulance transport to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from September 7, 2020, to September 11, 2020.  
You asked the Plan to pay for the inpatient care as billed. You say that the claim was billed correctly. The Plan denied your request. The Plan says the DRG was reduced as the principal diagnosis is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, unspecified organism. We asked our coding 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 inpatient care as billed. Our reviewer says that the billed principal diagnosis code is not supported. Our coding reviewer found documentation throughout this hospital stay does not document an acute change of more than 2 sepsis-related organ dysfunction assessments (SOFA) and known or suspected infection.    
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from September 7, 2020, to September 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve neuropsychological testing.  You asked the Plan to pre-approve neuropsychological testing. You say that the enrollee's neuropsychological condition needs evaluation to determine the best care. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee does not meet coverage criteria.  The Plan follows Medicare rules. Medicare rules state that neuropsychological testing may be covered under certain conditions.  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 neuropsychological testing. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested neuropsychological testing. Our physician reviewer found you are requesting an excessive amount of neuropsychological testing beyond what Medicare rules approve. The enrollee has shown impaired function as documented. He has been showing difficulty with cognitive issues as outlined using the interpretation. There is no documentation that justified the requested extra amount of time in testing and assessment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on November 1, 2021.  You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, and bitewing x-rays. You say that you asked if the provider accepted your plan and were told yes. You also say that you received a bill that you need to pay for the x-ray and insurance covered nothing. The Plan denied your request. The Plan says these benefits had been exhausted.  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, oral evaluation, intraoral periapical x-rays, and bitewing x-rays are each limited to once per 6 months. The record shows that you received a problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and bitewing x-rays (D0272) on May 24, 2021 and your oral evaluation, intraoral periapical x-ray, and bitewing x-ray benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lift chair (E0627) provided on July 6, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a lift chair. You say that you did not receive any information concerning reimbursement from Medicare for your purchase of a lift chair. The Plan denied your request. The Plan says while you are a member of our plan, you must use network providers to get your medical care and services. The Plan also says that the only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.  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 a lift chair (E0627) provided on July 6, 2021 by an out-of-network (OON) provider.
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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 that on review of the available records you have debility from recent urinary tract infection (UTI) and sepsis, is stable and does not meet Medicare coverage criteria for an IRF admission. With your current medical stability, and no other acute medical complexity, there is no need for physical medicine and rehabilitation (PM&R) physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs noted in the record. At your current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and with no rehab nursing needs and high functional level.   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 pre-approve oncology care with a tertiary level of care provider.  You asked the Plan to pre-approve oncology care. You say that this is your original oncologist throughout your entire treatment, and you do not feel confident with a lower level of care. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not need to be treated at the tertiary level of care and can be treated by a community-level oncologist instead.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   
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 oncology care. Our reviewer says that you do not meet the Medicare criteria for treatment at the tertiary level of care. Our physician reviewer found you are on surveillance for a history of breast cancer diagnosed in 2016 and maintained on letrozole. This is a standard therapy and can be easily followed by a community-level oncologist. There is nothing unique about your condition that would make it medically necessary for you to see the requested tertiary level provider. The Plan has shown that they have community-level providers who meet the Standards of Care for treatment of your condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oncology care have not been met. Therefore, we decided that the Plan does not have to pre-approve oncology care with a tertiary level of care provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OneTouch Verio test strips.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from the preferred providers.  The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies.  We looked at the file and Medicare rules. The requested test strips are not from the Plan's preferred provider. The services are available from one of the preferred providers. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio test strips.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex device.  You asked the Plan to pre-approve Vertiflex 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 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 chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has had an magnetic resonance imaging (MRI) that demonstrated central canal stenosis and multi-level degenerative disease. The MRI report is not available for review. The record does not state that the enrollee is not indicated for operative intervention and no more than two levels. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visit services with a pulmonologist.  You asked the Plan to pre-approve the pulmonology office visit services. You say that you had a pulmonology appointment scheduled for December 20, 2021, as a follow-up to a sleep study. You say that you do not have a PCP and want the health plan to call the pulmonologist's office in order to obtain evidence of medical necessity. The Plan denied your request. The Plan says, in order to see a specialist, you must first get approval from your PCP.  Medicare rules say that plans can require enrollees to obtain authorization before receiving services. The contract with the Plan says that enrollees must get a referral from their PCP prior to seeing a specialist.   The requested provider in this case is a pulmonologist. This type of provider is considered a specialist. There is no evidence of a referral from your PCP for these specialist services. Therefore, we decided that the Plan does not have to pre-approve office visit services with a pulmonologist.