Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve additional non-emergency transportation. You say that you need an
authorization for extra trips before the end of the year. The Plan denied your request. The Plan says your
transportation benefit of 10 one-way trips per year is exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of up to 10 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing care provided on September 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing care. 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 subsequent nursing care provided on September 13, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary to able retrieve the mail, access the local neighborhood, and to use in stores and for medical appointments. The Plan denied your request. The Plan says there is no evidence that this is medically necessary.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee's ongoing care needs. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate care in the current acute care hospital, and an LTACH would not provide a therapeutic advantage.
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 pay for 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 indicating medical necessity for LTACH services. 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 acute care hospital where she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis. 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 pay for long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.

You asked the Plan to pre-approve a power mobility device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that your condition can be improved by a walker or a cane. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you could
receive care in another setting such as skilled nursing facility, outpatient setting or home health 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 the health plan's denial should be upheld. You do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen (15) hours per week of rehabilitative
services and regular physician evaluation.
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a knee brace.
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your
request. The Plan says the services are being requested are with a non-contracted 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
an out-of-network referral for a knee brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prosource nutritional support.

You asked the Plan to pre-approve the Prosource nutritional support. You say that you would like reconsideration because you have had greater than 2% weight loss in one week prior to prescribing nutritional support. The Plan denied your request. The Plan says this is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Prosource nutritional support.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there should be a course of physical therapy before imaging to see if the symptoms can be resolved, and to forestall any surgical or procedural interventions.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found the x-rays showed mid degenerative arthritis, and the physical exam was essentially unremarkable. The chart notes show contemplation of physical therapy and orthopedic referral. There are no red flags mandating immediate magnetic resonance imaging (MRI) without first trying six weeks of supervised physical therapy. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous vertebroplasty (22511).
You asked the Plan to pre-approve the percutaneous vertebroplasty (22511). You say that the member's pain
has been debilitating and has not been relieved with anti-inflammatory medications or physical therapy. You
say that the procedure is medically appropriate and necessary to get her pain at a manageable level. The Plan
denied your request. The Plan says this procedure is considered not medically necessary at this time and cannot
be approved.
The Plan must follow Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and
necessary when certain criteria 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 the percutaneous vertebroplasty
(22511). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that the sacroplasty with cement is experimental. More
research is needed to show safety and efficacy of cement use for sacral fractures.
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 percutaneous vertebroplasty (22511) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the percutaneous vertebroplasty (22511).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pyridostigmine.

You asked the Plan to pre-approve Pyridostigmine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pyridostigmine.

Benefits for Pyridostigmine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that if you do not get this therapy your legs will not be as 
strong as they were before. You state that you are afraid your life will be endangered in many different ways 
and are a risk for falling. The Plan denied your request. The Plan says the stay is not medically necessary based 
on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: a 
skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.

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 health plan's denial should be upheld. You do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require fifteen (15) hours per week of rehabilitative 
services and regular physician evaluation. Your care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve the therapy. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found whether proton therapy affords a benefit over other standard approaches such as intensity-modulated
radiation therapy or image-guided radiation therapy (IMRT/IGRT) for prostate cancer is an area of
investigation and remains controversial. The enrollee agreed to consent to a registry study. This registry study
enrolls any patient receiving proton therapy for any disease, which should not be sufficient for claiming
medical necessity, as any and all patients treated with radiation therapy could then be considered for proton
therapy without consideration for true need of this service. Notably, registry studies are not clinical trials or
studies, and have a much less rigorous development process. A tumor registry does not address a specific
scientific question but rather registers the patient's clinical and treatment information into a database for
potential analysis in the future. Nevertheless, it is not specified if a clinical trial review was sought. To date,
there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT.
The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical
trials, and to not routinely offer it to patients.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve proton beam radiation therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 19, 2021.
You asked the Plan to pay for the services. You say that this should be paid at the correct rate. The Plan denied your request. The Plan says the provider is out-of-network and there was no 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 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 May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation over the 50-mile limit.

You asked the Plan to pre-approve routine transportation over the 50-mile limit. You say that this surgery is going to help reduce the pain, but you don't have a ride. The Plan denied your request. The Plan says the requested mileage is over your benefit limitation.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 100 one-way trips, up to 50 miles per trip.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation over the 50-mile limit have not been met. Specifically, the distance to the providers office exceeds the 50-mile limit. Therefore, we decided that the Plan does not have to pre-approve routine transportation over the 50-mile limit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that this treatment is
considered safe and effective as supported by clinical benefits to patients, continued medical profession
adoption and strong clinical evidence. You say that the per-authorization should be approved for the coverage
your patient is entitled to. The Plan denied your request. The Plan says there is a lack of evidence to support
interspinous spacer devices as safe and effective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the insertion of stabilization device
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found Interspinous distraction devices are 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 the insertion of stabilization device (22869) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at
24-hour facility, in addition to basic service coded 99053 provided on February 23, 2021.
You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in
addition to basic service. You say that you would like the plan to reconsider their denial. The Plan denied your
request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00
AM at 24-hour facility, in addition to basic service.
We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status code of
B. This means that payment for covered services are always bundled into payment for other services not
specified and no separate payment can be made. Based on this information, we decided that Medicare rules for
coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic
service have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided
between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on
February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation feature (E2300).
You asked the Plan to pre-approve power seat elevation feature. You say that you need this. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature.
We looked at the file and Medicare rules. The requested item is not medical in nature. Based on this
information, we decided that Medicare rules for coverage of power seat elevation feature have not been met.
Therefore, we decided that the Plan does not have to pre-approve power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed