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

We decided that the Plan does not have to pre-approve cochlear device implantation.

You asked the Plan to pre-approve the implantation. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service 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 the implantation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare guidelines state cochlear implantation is indicated for patients with bilateral moderate-to-profound sensorineural hearing loss who demonstrate limited benefit from amplification.

Medicare states that "FDA approval/clearance alone does not entitle that device to coverage. The device must fall under a Medicare benefit category and be determined to be reasonable and necessary. Thus, FDA approval by itself is not sufficient for making a determination concerning Medicare coverage." Although this enrollee meets FDA criteria for a cochlear implant, she does not meet Medicare criteria for coverage of the device and the surgery to place the device. Because this member has somatic symptom disorder, she does not meet Medicare coverage criteria as per the NCD.

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 implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve cochlear device implantation.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's condition is not medically complex enough to require an intensive medical team for care or a rehabilitation doctor for evaluation at least three times a week. The Plan says that the enrollee can safely receive the services in needed in another 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 above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.

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
physician's services. 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 physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.

You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says there is insufficient clinical information to approve the requested study is medically necessary.

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 criteria for coverage have not been met. Our physician reviewer found the documentation does not show that a recent x-ray or computed tomography (CT) scan had been performed with equivocal results or report of history of signs and symptoms suggestive of radiculopathy, mass, or other soft tissue changes to justify MRI cervical spine at this time. The requested MRI is not considered 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with written report (85060).

You asked the Plan to pay for hematology and coagulation procedures. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says inappropriate place of service for physician interpretation per Medicare guidelines.

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, review of the claim shows the provider billed with place of service 22, for outpatient hospital. CPT code 85060 is used only when a physician interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and the hospital is responsible for the technical component. When an independent laboratory bills a physician interpretation of an abnormal peripheral blood smear, the service is considered a complete or global service, and is not billed under the CPT code 85060. Based on this information, we decided that Medicare rules for coverage of hematology and coagulation procedures have not been met. Therefore, we decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with written report (85060).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93000) and follow-up office visit (99214) provided by an out of network (OON) provider.

You asked the Plan to pay for the office follow-up and ECG. You say that this was a medically necessary follow-up to a previous procedure rendered six months prior. You say you were told by the primary care physician that no referral or prior authorization was needed. The Plan denied your request. The Plan says they require the enrollee to receive in-network care whenever possible. Prior authorization was not obtained, and there was no referral provided or referring provider listed in the claim. The services were not documented as urgent or emergent, and there are several in-network providers available who would have been able to provide this care.

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 electrocardiogram (ECG) (93000) and follow-up office visit (99214) provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye wear polarization and flash mirrored coating provided on June 29, 2020.

You asked the Plan to pay for the eye wear polarization (V2762) and flash mirrored coating (V2797). You say that the features help you see more clearly and make you safer on the road. The Plan denied your request. The Plan says non-listed services are not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the listed services, non-listed services are not covered. You can find this information on page 90 of the Plan's 2020 Evidence of Coverage. If elected, member is responsible for all non-covered services. 

We looked at the file and the Plan's rules. The lens options are not listed in the EOC therefore, you are responsible for the charges. Based on this information, we decided that the Plan's rules for coverage of the eye wear polarization (V2762) and flash mirrored coating (V2797) have not been met. Therefore, we decided that the Plan does not have to pay for the eye wear polarization and flash mirrored coating provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammography provided on October 14, 2020.
You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 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 a mammography provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture.
You asked the Plan to pre-approve a partial lower denture. You say that you lost your partial lower denture a while ago. The Plan denied your request. The Plan says you received a partial lower denture on April 24, 2019 which is less than 60 months ago.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture.
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 services are medically necessary. The Plan denied your request. The Plan says you can benefit from a lower level of 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 above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and you do not require an intensive inpatient rehabilitation therapy program. 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, you can receive care at a lower level of care. This means that admission to an IRF is not medically necessary or reasonable. 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: Favorable

We decided that the Plan has to pay for the office visit (99203) provided on October 9, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the services rendered were medically necessary and provided by a network provider. The Plan denied your request. The Plan says that the service performed, the servicing provider, or the number of visits billed do not match what was approved on the authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan states that an approved authorization exists. The Plan has not forwarded that authorization for review, therefore the denial is not substantiated. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the office visit (99203) provided on October 9, 2020.
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 skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says the enrollee's care can be managed at a lower level of care and that the guidelines for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and a course of IV antibiotics. The enrollee had stable vital signs and clear lungs. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was independent with functional mobility, including gait to 200 feet with no assistive device. The enrollee was independent with activities of daily living. The enrollee had ongoing cognitive deficits. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 pre-approve occipital radiofrequency ablation.

You asked the Plan to pre-approve occipital radiofrequency ablation. You say that the requested treatment is of the enrollee's occipital nerves, posterior, and more cephalad to her spinal structures. The appellant says that it has been 2 years since the enrollee's last occipital nerve radiofrequency ablation treatment and her headaches are worsening despite conservative management, including pharmacotherapy. The Plan denied your request. The Plan says the guidelines have not been met for coverage of the requested 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 occipital radiofrequency ablation. Our reviewer says that occipital radiofrequency ablation is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure because large scale prospective randomized trials have not been conducted.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occipital radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve occipital radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional glucose supplies (A4253, A4259).

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 services. Our reviewer says that the requested additional supplies are not considered medically reasonable and necessary in this case. Our physician reviewer found the last physician note and the case file indicates that this prescriber is no longer your physician. The request is for additional blood glucose monitoring supplies in excess of the typical amount to allow testing of blood sugar twice a day. In this case, you are not on insulin. The record does not indicate that there has been a physician visit in over a year. Therefore, the criteria for coverage of additional diabetes supplies are not satisfied and coverage cannot be recommended.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional glucose supplies (A4253, A4259).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT code 95999) provided to the enrollee on October 15, 2020.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare guidelines say that this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The enrollee had spinal surgery. The record sent by the provider indicates that the enrollee underwent neck surgery requiring neurophysiology monitoring. Under Medicare guidelines, the request for procedure code, 95999, is not a covered benefit because Medicare does not make separate payment for this service. Therefore, we decided that the Plan does not have to pay for train of four testing (CPT code 95999) provided to the enrollee on October 15, 2020.