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

We decided that the Plan does not have to pre-approve Vertiflex Superion Device.
You asked the Plan to pre-approve Vertiflex Superion Device. 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 Vertiflex Superion 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 been diagnosed with spinal stenosis with neurogenic claudication. The enrollee gets relief from injections for short period of time anywhere from days to weeks but then the enrollee's pain ultimately returns. Evidence is lacking for the requested services, large well-designed studies in the peer review scientific literature comparing stand-alone use of Superion device to established surgical decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Superion as an alternative to standard surgical treatment. 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 Vertiflex Superion Device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown (D2740) on tooth 6 and 7 and a root canal (D3310) on tooth 6, 7 and 10.

You asked the Plan to pre-approve dental codes D2740 and D3310. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services requested for D2740 and D3310 exceeds your benefit limit. The Plan says that you were approved for D2740 and D3320 on tooth 5 on January 25, 2021.

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.

We looked at the file, the Plan's contract and Medicare rules. In this case, you are requesting dental codes D2740 and D3310. Your Plan contract clearly shows these services are covered once per year. The file shows that the Plan approved these dental services on January 25, 2021. Therefore, we decided that the Plan does not have to pre-approve a dental crown (D2740) on tooth 6 and 7 and a root canal (D3310) on tooth 6, 7 and 10.
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.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a myocardial infarction. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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. 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 shoe inserts.

You asked the Plan to pre-approve these services. You say that you have hip and back pain due to limping while walking. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve shoe inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided by an out of network (OON) provider.

You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained before this service was rendered.

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 automatic external defibrillator (K0606) provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99284, CPT 93010) provided to the enrollee.

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 claim was processed correctly per how the provider billed the services.

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 the denied codes is:

CPT 99284:

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity.

CPT 93010:

Electrocardiogram, routine ECG with at least 12-leads; interpretation and report only.

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided do not include sufficient documentation to verify the required elements defined in CPT coding requirements for CPT 99284 was met, therefore this service cannot be verified.

We looked at this coder'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 pay for emergency department services (CPT 99284, CPT 93010) provided to the enrollee.
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.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for quantitation of therapeutic drug (80299), column chromatography (82542), mass spectrometry (83789) and drug testing services (G0482).

You asked the Plan to pay for quantitation of therapeutic drug, column chromatography, mass spectrometry and drug testing services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the billed services are 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 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 quantitation of therapeutic drug, column chromatography, mass spectrometry and drug testing services. Our reviewer says that the services provided are not supported by the medical records. Our physician reviewer found the documentation submitted was reviewed and does not meet criteria. Code G0482 is not supported by the laboratory report submitted, as 15-21 drug classes were not tested. Therefore, neither G0482 nor the remaining codes at issue are supported.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of quantitation of therapeutic drug, column chromatography, mass spectrometry and drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for quantitation of therapeutic drug (80299), column chromatography (82542), mass spectrometry (83789) and drug testing services (G0482).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids.

You asked the Plan to pay for the hearing aids. You say that you were informed of the enrollee's benefits that covers up to $2,000.00 for hearing aids and supplies every 2 years, and that the enrollee can go to any contracted provider. The Plan denied your request. The Plan says you are not a contracted network provider that the enrollee is allowed to use according to their 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 enrollee's 2020 EOC says that to be covered, the enrollee must use a plan approved provider. This provider is not a plan approved provider. Further research found that there are plan approved providers within a reasonable distance of the enrollee's home. Therefore, we decided that the Plan does not have to pay for the hearing aids.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no complex wound care or other skilled nursing need. The enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781).

You asked the Plan to pay for progressive lenses. You say that you were told these items would be reimbursed. The Plan denied your request. The Plan says rules for payment have not been met.

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 routine eye examinations once per year.

We looked at the file and the Plan's rules. The Plan contract states that the Medicare benefit covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. However, tinting, scratch protection, or other enhancements to eyewear are not covered. There is no provision in the Plan's routine vision benefit for enhancements to eyewear. Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781).

Your complaint about receiving erroneous or ambiguous information about your benefits from the provider or from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tablets.

You asked the Plan to pre-approve Prednisone tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Prednisone tablets are not covered under the enrollee's Medicare Part B 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 Prednisone tablets.

Benefits for Prednisone tablets 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 long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. 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 he/she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve additional acupuncture visits.

You asked the Plan to pre-approve the additional acupuncture visits. You say that you were advised the requested acupuncture would be covered for her condition. You say that your previous acupuncture visits have helped your back pain. The Plan denied your request. The Plan says that the requested treatments are not medically necessary at this time. The Plan also says that the requested acupuncturists does not have an active unrestricted license in the state where the services would be performed.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

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 additional acupuncture visits. Our reviewer says that the criteria for coverage of an additional 8 acupuncture visits have been met. Our physician reviewer found the enrollee has chronic low back pain described as a dull ache over L2-L5 and extending into the Right Gluteus and the sacrum. The enrollee has received a series of acupuncture treatments and demonstrated improvement.

We looked at this physician's review, the file, and Medicare rules. We also researched the Plan's claims that the requested provider is not licensed in the State. Medicare rules specifically say that the provider needs to be licensed in a state and does not specify that it must be the state in which services are rendered. The provider's NPI supports this. In addition, we found that the provider does have an active license to practice acupuncture in the State.

This, along with our physician reviewer's determination, supports that the Plan has not substantiated their denial reasons. Based on this information, we decided that Medicare rules for coverage of the additional acupuncture visits have been met. The records show that the enrollee has already received 12 acupuncture visits in the 2021 calendar year. A maximum of 20 acupuncture visits are allowed per calendar year under the Medicare benefit allowance for this type of service. Therefore, we decided that the Plan has to pre-approve 8 additional acupuncture visits.

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: 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 enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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.