Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on August 4, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve Laparoscopic Roux-en-Y Gastric Bypass.  You asked the Plan to pre-approve Laparoscopic Roux-en-Y Gastric Bypass. You say that this surgery is crucial to your existence. The Plan denied your request. The Plan says that the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that medical documentation may be submitted for review for repeat bariatric surgery and the service may potentially be covered when clinical circumstances demonstrate reasonability and necessity  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 Laparoscopic Roux-en-Y Gastric Bypass. Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found you have super obesity with a body mass index of 51 kg/m2. You have an obesity co-morbid condition including sleep apnea. Dietary and psychological clearance was obtained. You have failed numerous dietary efforts in the past including lap band surgery, which was removed secondary to complications of the device. You, therefore, have no current bariatric treatment. Unlike gastric bypass or sleeve gastrectomy, the lap band is a device, which when removed offers no weight loss support. You meet all primary Medicare guidelines for bariatric surgery at this time. As this is a request for repeat bariatric surgery, general medical necessity guidelines are considered. You meet all standard nationally accepted criteria for bariatric surgery, including the American Society for Metabolic and Bariatric Surgery guidelines and should be afforded a stapled metabolic bariatric procedure, as you are currently without any tool or permanent change to your anatomy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Laparoscopic Roux-en-Y Gastric Bypass have been met. Therefore, we decided that the Plan has to pre-approve Laparoscopic Roux-en-Y Gastric Bypass.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home after, or in any setting.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lumbar support orthotic (L0631), provided on August 10, 2020.  You asked the Plan to pay for the lumbar support orthotic. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no physician order or proof of delivery.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order, or proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar support orthotic (L0631), provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections (repeat diagnostic medial branch blocks (MBBs)).  You asked the Plan to pre-approve facet joint injections. You say that you have a lot of discomfort and this procedure would be great. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you only received 50% pain relief from the first injections and not the required 80% pain relief.  The Plan follows Medicare rules. Medicare rules state that a second confirmatory diagnostic facet joint procedure is covered for enrollees who met criteria for the first diagnostic procedure and after the first procedure had a consistent positive response of at least 80% pain relief.  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 facet joint injections. Our reviewer says that you do not meet the Medicare criteria for the requested second diagnostic medial branch blocks. Our physician reviewer found you have left-side neck and shoulder pain. You take Tylenol, magnesium lotion, and biofreeze for pain. You had cervical diagnostic medial branch blocks that produced only 50% pain relief. The Medicare requirement is 80% pain relief, therefore this request 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (repeat diagnostic medial branch blocks (MBBs)).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the recliner (E1399).  You asked the Plan to pre-approve the recliner. You say that you need this item. The Plan denied your request. The Plan says this item is not covered.  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 pre-approve the recliner (E1399).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve a combination of Carboplatin and Paclitaxel.  You asked the Plan to pre-approve Carboplatin and Paclitaxel. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for these drugs is correct, because this combination is not supported in the guidelines for the enrollee's type of cancer.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Carboplatin and Paclitaxel. Our reviewer says that the enrollee meets the Medicare criteria for the requested combination of Carboplatin and Paclitaxel. Our physician reviewer found the requested use of Carboplatin and Paclitaxel is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. However, the requested use is supported by the National Comprehensive Cancer Network (NCCN) drug compendium. The documentation supports that this combination is safe and effective and otherwise medically reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin and Paclitaxel have been met. Therefore, we decided that the Plan has to pre-approve a combination of Carboplatin and Paclitaxel.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE).  You asked the Plan to pre-approve PAE. You say that this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not shown that this service 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 PAE. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostate hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. This procedure is not recommended outside of a clinical trial setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE).
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he 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 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 the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 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 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 7, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from December 7, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  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 from December 7, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of December 7, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 7, 2021, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  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 from December 7, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 7, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gynecological oncology visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve specialist visits. You say that you disagree with this denial. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.  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 gynecological oncology visits to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the sleep study provided on June 8, 2021.  You asked the Plan to waive the copayment for the sleep study. You say that you were told the service would be covered and you have to pay out-of-pocket. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $150 copayment for all other diagnostic procedures and tests. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $150 copayment for the sleep study.     You have been asked to pay a $105.39 copayment for the sleep study. The sleep study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the sleep study is considered a diagnostic test. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the sleep study provided on June 8, 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. 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 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the CT scan and the partial nephrectomy provided from June 11, 2021, to June 24, 2021.  You asked the Plan to waive the copayments for the CT scan and the partial nephrectomy. You say that you want to appeal these charges. You say the Explanation of Benefits states the hospital is out-of-network.  The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $100 copayment for in-network diagnostic radiology (CT, MRI, PET scan, etc.) and a $275 copayment for in-network outpatient hospital visits.   You have been asked to pay a $100 copayment for the CT scan and a $275 copayment for the partial nephrectomy. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefits category. The partial nephrectomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. The record shows you were charged the in-network amounts for the CT scan and the partial nephrectomy.   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 the CT scan and the partial nephrectomy from June 11, 2021, to June 24, 2021.