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

 We decided that the Plan does not have to pay for drug testing (80307) provided on September 23, 2021 by an out-of-network (OON) provider.  
You asked the Plan to pay for drug testing. You say that the patient's specimens were sent to your laboratory as per the order form. You also say that the patient was expecting to receive the same level of coverage with this insurance as he was from the traditional Medicare. 
You also say that you are an out of network lab and that you see the patient has no out of network benefits, but all of the codes submitted are Medicare approved codes. The Plan denied your request. The Plan says the provider is a non-participating provider. The Plan also says that the referring provider is a non-participating provider. The Plan also states that they have also determined that these services are not urgent or emergent, nor were they 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 drug testing (80307) provided on September 23, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Accucheck Smartview Glucose Test Strips.  You asked the Plan to pre-approve the Accucheck Smartview Glucose Test Strips. You say that these are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says you must demonstrate that the Plan's preferred brand of test strips will not be sufficient for the enrollee's condition before this will be approved.  
The Plan must follow Medicare rules. The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. In this case, medical records were requested to confirm the medical necessity of the requested test strips over the Plan's preferred brand. A response to this request was not received. Based on this information, we decided that Medicare rules for coverage of the Accucheck Smartview Glucose Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Accucheck Smartview Glucose Test Strips.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure (CPT code C9752), for the enrollee.  You asked the Plan to pre-approve the service. You say that the intracept procedure is medically necessary and the most effective treatment. The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain and it is considered experimental and investigational.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code C9752), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shoulder arthroscopy procedure with rotator cuff repair.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has not tried non-operative treatment.  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 requested services. Our physician reviewer found that the enrollee is being treated for calcific tendinitis of right shoulder; superior labrum anterior-to-posterior (SLAP) tear of right shoulder; and trigger finger of right and left ring finger. He presented with right shoulder pain and stiffness for several months. He has complaints of weakness and stiffness as well as pain with range of motion. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is notation of physical therapy, however, it is not clear that this has been recent and failed to relieve the symptoms. Additionally, documentation is not evident regarding the trial and failure of an injection to potentially treat painful inflammation.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request. Therefore, the request for right shoulder arthroscopy with rotator cuff repair is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoulder arthroscopy procedure with rotator cuff repair.
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 the level of care provided in an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.
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 based on the medical records provided, the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical therapy and occupational therapy services, the records provided do not show that you require an intensive inpatient rehabilitation therapy program provided in an IRF. Care at a skilled nursing facility level appears to be appropriate in this case. 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.  You asked the Plan to pre-approve HBO therapy. You say that the enrollee has a non-healing leg ulcer which is secondary to sickle cell anemia. The Plan denied your request. The Plan says the requested treatment is not considered medically necessary for the enrollee's condition.  The Plan follows Medicare rules. Medicare rules say that HBO therapy is covered for certain medical indications.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve HBO therapy. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record sent by the enrollee's provider indicates that he has swelling and varicose veins causing a venous wound of the ankle. Conservative methods have been inadequate, and the provider has recommended hyperbaric oxygen therapy. Hyperbaric oxygen therapy is not covered for Cutaneous, decubitus, and stasis ulcers/Chronic peripheral vascular insufficiency.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift chair with lift mechanism.  You asked the Plan to pre-approve seat lift chair. You say that you have a severe leg issue and have a hard time standing on your own The Plan denied your request. The Plan says the denial of authorization for this device is correct, because there are no records showing that you meet criteria.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for an item, the information submitted by the provider must corroborate the documentation in the medical record and confirm that coverage criteria have been met. The rules say that a seat lift mechanism is covered if all of the conditions listed in the previous section are met.  We looked at the file and Medicare rules. Your treating provider did not submit any supporting records for this request. The Plan made attempts to obtain medical records, but none were submitted. Without supporting records, we cannot determine whether you meet criteria for a seat lift mechanism. Based on this information, we decided that Medicare rules for coverage of seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair with lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve back surgery at spinal level L2-5.  You asked the Plan to pre-approve back surgery. 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 back surgery. 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 back pain. The criteria for spinal fusion surgery not met. There is no radiographic documentation of instability on radiology reports. There is no documentation of at least three months of conservative care to include physical therapy. 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 back surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve back surgery at spinal level L2-5.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT code 74177), for the enrollee.  You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says that the service is not necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer found there is no history of upper abdominal pain, so the lack of pancreatic enzyme lab work is not important. The enrollee had a normal colonoscopy in 2016 with follow-up recommended in ten (10) years. Ultrasound of the male pelvis would not be an exam of high yield. The requested CT of the abdomen and pelvis is thus reasonable and the best way to image the area of clinical concern, the left lower quadrant. Due to the normal white count diverticulitis is unlikely but abdominal hernia, mass, lymphadenopathy would be possible and assessed with CT.  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 CT scan have not been met. Therefore, we decided that the Plan has to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT code 74177), for the enrollee.   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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy (G0283, 97140, 97110) provided on August 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for physical therapy. You say that the enrollee is enrolled in a Medicare Dual Plan and is entitled to all Medicare approved services. You also say that the individual provider, as well as the referring provider are participating providers with Medicare. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.  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 physical therapy (G0283, 97140, 97110) provided on August 16, 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 the enrollee prefers to be admitted to a higher level of care so that they have the medical management and therapy that will help them to get to their goal of returning home. The Plan denied your request. The Plan says the requested IRF admission is not medically necessary.  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 provided documentation indicates the enrollee does not have complex nursing or rehabilitation needs. The reviewer found that while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Specifically, the file shows that there is no documentation of a need for an intensive rehabilitation program. 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 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 is still with a chest tube, duration of which is not known. At the current functional level and inability to tolerate therapies, the enrollee does 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.  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 pay for the consult (D9310) provided on August 18, 2021, by an OON provider.  You asked the Plan to pay for the consult. The Plan denied your request. The Plan says this service is not a covered benefit when rendered by a dentist who does not participate in the program. The Plan also says that consultation services are excluded from your benefit plan.    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, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the consult (D9310) provided on August 18, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.  You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MyoPro Motion G Orthotic 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 a past medical history of stroke with left sided paralysis. There is no documentation that the MyoPro Motion G Orthotic device at issue in this case meets Medicare criteria for medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. Therefore, the enrollee does not meet criteria for the requested device.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ophthalmology services provided by a tertiary level provider.  You asked the Plan to pre-approve the ophthalmology services. You say that you had a bad experience with the approved provider, and you will not go back there. You say that your doctor recently retired and recommended this provider. The Plan denied your request. The Plan says the member does not meet tertiary care guidelines.   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 the ophthalmology services. Our reviewer says that the plan has a contracted provider that can provide services. Our physician reviewer found that you have bilateral cataracts, and the record does not indicate any medically sufficient rationale why you cannot receive care at the contracted provider.  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 ophthalmology services have not been met. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services provided by a tertiary level provider.