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

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE).
You asked the Plan to pre-approve the WCE. You say that this is necessary. The Plan denied your request. The Plan says the need for this is not supported.
The Plan follows Medicare rules. Medicare rules say that WCE may be considered reasonable and necessary when certain criteria, listed in the Medicare rules section, are 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 WCE. Our reviewer says that the requested services are not considered medically necessary in this case. Our physician reviewer found the record indicates that the enrollee has previously had a capsule endoscopy. The medical record provided does not indicate the presence of any covered indications. The elements of the coverage criteria are not satisfied. 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 WCE have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy (WCE).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for visits you had at a wound care specialty
office from May 21, 2021, to June 21, 2021.
You asked the Plan to reduce the copayments for the wound care specialty visits. You say that because you
only saw physician's assistants on these dates, you should only have to pay the primary care copayment, not the
specialist copayment. The Plan denied your request. The Plan says you were charged these copayments
correctly.
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 $40
copayment for physician and practitioner services in a specialist's office.
You have been asked to pay a $40 copayment for the wound care specialty visits. The copayment is based on
the location where the services were rendered. These services were rendered in a specialty office, so the
specialty copayment applies. Your contract says that this copayment applies to practitioner (i.e., nonphysician)
services as well as physicians. 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 reduce the copayments for visits you
had at a wound care specialty office from May 21, 2021, to June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation services.
You asked the Plan to pre-approve genicular nerve radiofrequency ablation services. You say that this request is medically necessary. The Plan denied your request. The Plan says regarding this procedure, this research has to show that this is as good as or better than other treatments or procedures.
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 genicular nerve radiofrequency ablation services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve ablations are considered experimental/investigational in nature. The requested genicular nerve ablations are not reasonable and medically 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 genicular nerve radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
osteomyelitis requiring amputation of the great toe, coronary artery bypass grafting, renal failure requiring 
initiation of dialysis and metabolic encephalopathy. Your medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vascular embolization procedure (coded as 37242), and the angiography of the abdominal and lower extremity vessels (75625, 75710, 75716).
You asked the Plan to pre-approve these additional vascular procedures. You say that this should be approved. The Plan denied your request. The Plan says the treatment itself has been approved; however, the additional services are not supported as needed.
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 additional vascular procedures. Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found though the prostate embolization is supported, there is insufficient support to warrant the angiograms which are typically not used during this procedure. Therefore, the angiography testing will be considered not medically necessary at this time. 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 additional vascular procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve the vascular embolization procedure (coded as 37242), and the angiography of the abdominal and lower extremity vessels (75625, 75710, 75716).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 24, 2021,
to April 29, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you were told that the SNF stay
would be fully covered. 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 $0
copayment for days 1-20, and a $184 copayment for days 21-100 for SNF care.
You had a SNF stay from March 24, 2021, to April 30, 2021. You are not being charged a copayment for days
1-20 (March 24, 2021, to April 12, 2021). You are responsible to pay a copayment for days 21-37 (April 13,
2021, to April 29, 2021). The total amount you owe is: $184 (copayment) x 17 (SNF days) = $3,128.
You have been asked to pay the total copayment amount of $3,128 for a SNF stay. A SNF stay falls within the
SNF 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 copayment for a SNF stay provided from
March 24, 2021, to April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Iovera neuroablation procedure (64640).
You asked the Plan to pre-approve an Iovera neuroablation procedure. You say that you need this procedure to treat your pain. The Plan denied your request. The Plan says this is experimental.
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 an Iovera neuroablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental and investigational. It has not been proven to be safe or effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Iovera neuroablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Iovera neuroablation procedure (64640).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 11, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The 
claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of 
a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurologist office visit (99214) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a neurologist office visit. You say that you have seen this doctor before. The Plan denied your request. The Plan says there are in-network neurologists who can provide the requested service.
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 a neurologist office visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cardiac catheterization and related services you received at an outpatient hospital on June 1, 2021, and June 2, 2021.

You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that when you arrived at the hospital, that was the first time you had received notification about these charges. You believe the charges are incorrect. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

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 20% coinsurance for diagnostic procedures and tests at an outpatient hospital facility. 

You have been asked to pay 20% coinsurance for the outpatient hospital services. The services you received fall within the diagnostic procedures and tests at an outpatient hospital facility 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 coinsurance for the cardiac catheterization and related services you received at an outpatient hospital on June 1, 2021, and June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (11043) provided on April 7, 2021.

You asked the Plan to pay for the debridement services. You say that you would like reconsideration because
the diagnoses are different. The Plan denied your request. The Plan says this service is included in the global
package for CPT code 10060.

The Plan must follow Medicare rules. Medicare rules say that Postoperative Visits are included in the global
surgical package.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the debridement services have not been met. Specifically, the record indicates that this service is
related to the minor procedure. The debridement was rendered within the 10 day surgical package. Therefore,
we decided that the Plan does not have to pay for the debridement services (11043) provided on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (aducanumab) injections.
You asked the Plan to pre-approve the Aduhelm treatments. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says the current information is not sufficient to support the use of this drug in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Aduhelm treatments. Our reviewer says that the requested treatment is not shown to be medically reasonable and necessary in this case. Our physician reviewer found the documentation is not entirely consistent with a diagnosis of Alzheimer's disease, with an unremarkable magnetic resonance imaging (MRI) scan and no amyloid brain scan. Consequently, there is insufficient documentation to demonstrate that Aduhelm is medically reasonable and necessary for the enrollee in this case. It has not been shown that Aduhelm is at least as beneficial as the existing and appropriate medically appropriate alternatives of donepezil and memantine that this enrollee is taking. 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 Aduhelm treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (aducanumab) injections
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 your condition does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. The functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility discharge services provided on
October 26, 2020.
You asked the Plan to pay for nursing facility discharge services. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nursing facility discharge services provided on October 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says your needs are custodial.
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 daily skilled services are not necessary. Our physician reviewer found admission to an SNF is not reasonable and necessary as you have no skilled nursing needs and do not need skilled therapies on a daily basis in an inpatient setting at your current functional level. Your 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 19, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at this physician's review, the file, and Medicare rules. The file shows that prior authorization was obtained. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 19, 2021