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

 We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on August 20, 2021.  

You asked the Plan to pay for the office visit. You say that every doctor examines you before providing treatment. The Plan denied your request. The Plan says Medicare does not cover office visits performed by a chiropractor.  

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   

We looked at the file and the rules. Office visits, when provided by a chiropractor, are not covered by Medicare or your Plan. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from  August 30, 2021, through September 19, 2021.  

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services was not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from August 30, 2021, through  September 19, 2021. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment from August 30, 2021, through September 19, 2021. Daily skilled services were not required from August 30, 2021, through September 19, 2021. As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from August 30, 2021, through September 19, 2021.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from August 30, 2021, through September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on June 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  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 the office visit provided on June 10, 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 MyoPro 2 Motion G Orthotic Device for the enrollee. 

 You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of MyoPro orthotic device in the setting of a CVA with residual left hemiparesis have not been demonstrated in the peer-reviewed literature.  

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. 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. No documentation from the enrollee's hand-on treating provider or therapist describes in detail prior therapies that have been tried and failed and why the MyoPro 2 Motion G Orthotic Device is the best treatment option for her at this time. In addition, records document a left shoulder subluxation which may be a contraindication to the use of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic Device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xarelto 20MG tab, for the enrollee.  

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee does not have pharmacy (drug) benefits administered by this health plan. The Plan states the enrollee has prescription coverage through another plan.  

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 Xarelto 20MG tab, for the enrollee.   

Benefits for the medication 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: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  

You asked the Plan to pre-approve SNF care. You say that the enrollee is ready to be discharged from the current facility but needs assistance with daily activities. You say that the enrollee still needs help getting out of bed. The Plan denied your request. The Plan says that the guidelines for coverage of SNF care have not been met. The Plan says that SNF care is not medically reasonable and necessary. The Plan says that the services needed may safely be received from home health services and supervision at home or in an assisted living facility.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital.  Although the enrollee does not have any skilled nursing needs, he has had a significant decline in physical functioning.  The enrollee does require skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or complications. Admission to a skilled nursing facility for inpatient rehabilitation services is medically appropriate.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   

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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require skilled nursing or therapy services on a daily inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chiropractic services (procedure code 99203).  You asked the Plan to pre-approve the services. You say that this is needed to alleviate pain. The Plan denied your request. The Plan says the plan only covers manual manipulation of the spine to correct subluxation.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. The services were requested with procedure code 99203, which is for an office visit. This does not explicitly represent manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (procedure code 99203).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiovascular stress test provided on May 27, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that cardiovascular stress tests are covered for the indications established in the applicable LCD.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested stress test was not medically reasonable and necessary. Our physician reviewer found that the indication for the study was "screening for ischemic heart disease." There is no evidence provided that would support the need for radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in this enrollee's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular stress test provided on May 27, 2021.
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 a right hip fracture, status post-surgery, and are medically stable with no complications. With your comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. In addition, no acute or complex rehab nursing needs are noted in the record. With an uncomplicated hip fracture, 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. Your rehab needs can be met at a lower intensity setting. IRF admission is not medically necessary based on lack of medical complexity, and rehab nursing needs. Your rehab needs can be safely met in an alternate and lower intensity setting such as in an SNF.  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 pay for the anesthesia services coded 99100 provided on April 27, 2021.  You asked the Plan to pay for the anesthesia services. 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 separately 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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B". A status indicator of B means that payment for this service is 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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on August 12, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  

You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the need for inpatient psychiatric care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee has no medical problems that require hospital care.  

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 services. 

Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on January 14, 2022, with Major Depressive Disorder, Recurrent, Severe, without Psychotic Features and Rule out Generalized Anxiety Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment.  

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from February 21, 2020, to January 12, 2021.  You asked the Plan to waive the copayments for outpatient mental health care. You say that you did not see the provider on February 21, 2020 and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $25 copayment for outpatient mental health care.   The medical records show that you received outpatient mental health care from February 21, 2020, to January 12, 2021, for a total of 3 visits. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: $25 (copayment) x 3 (outpatient mental health care visits) = $75.   You have been asked to pay the total copayment amount of $75 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care benefit category. 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 outpatient mental health care provided from February 21, 2020, to January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for facet joint injection services.  You asked the Plan to pay for facet joint injection services. You say that the enrollee previously underwent C4-7 facet injections and had 80% relief of his neck pain. You say that the primary area of pain at this point is low back pain. The Plan denied your request. The Plan says the enrollee does not have pain that is localized to the low back which does not travel to other areas of the body.  The Plan follows Medicare rules. Medicare rules say that diagnostic facet joint procedures are covered for certain clinical 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 pay for facet joint injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee only received 70% pain relief which is not the 80% threshold as required. Therefore, the request is deemed 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 injection services have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injection services.