Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns on teeth #18, 20 and 22 and pontics on teeth #19 and 21.
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says that your request did not include the needed x-rays.
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. The Plan covers these services when the services are medically necessary and reasonable. 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 these services are not medically reasonable and necessary for the enrollee in this case. The provided x-rays are not of diagnostic quality, and do not show the involved teeth clearly, nor do they show the apicies of the teeth or bone levels that can be adequately assessed. The panoramic x-ray included in the record is unreadable. In order to find necessity for a fixed bridge the periodontal status of the teeth involved must be determined to be adequate to support the appliance with the additional loads placed on them when replacing the missing teeth. The teeth themselves must be free of endodontic involvement, or be treated for any pulp issue prior to bridge fabrication. There should reasonable opposing occlusion present or anticipated to be replaced by another prosthetic appliance to ensure function. 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 the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns on teeth #18, 20 and 22 and pontics on teeth #19 and 21.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 13,
2019 to November 14, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient level of care was medically
necessary. The Plan denied your request. The Plan says services could have been rendered on an outpatient
basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee was evaluated in the emergency department and diagnosed with
diverticulitis without abscess. Hospital care included antibiotics, analgesia, and repeat laboratory studies. Care
provided to the enrollee was observation level. There were no advance interventions or complex medical
conditions.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided November 13, 2019 to November 14,
2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvea facet joint block injection.You asked the Plan to pre-approvefacet joint block. You say that you are appealing withmedical records.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the treating physician needs to provide records for the results of a previously approved shot and why the enrollee needs this shot now.The Plan follows Medicare rules. Medicare rules say that facet joint block injections may be covered to treat facet joint cysts.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 facet joint block. Our reviewer says that the enrollee meets the Medicare criteria for the requested facet joint block. Our physician reviewer found the injection of the facet joint willrupture the facet joint cyst and probably relieve the facet joint mediated pain. That is why this exception for coverage is listed in the Medicare rules. Therefore, the requested procedure is medically reasonable and 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 block have not been met.Therefore, we decided that the Plan has to pre-approvea facet joint block injection.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 physical therapy visits for the enrollee.
You asked the Plan to pre-approve 30 physical therapy visits. 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. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 30 physical therapy visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the enrollee now walks with a walker. A progress note
indicates the enrollee has joint pain in the knee, hip, elbow, low back pain and chronic pain syndrome. Records
indicate the enrollee has a history of falls and she sees pain management. Without records of outcome of the
prior authorized 16 therapy visits it is not clear that the unique skills of a professional therapist are required to
safely and effectively provide treatment, that the services can be safely and effectively performed only by a
therapist, or under the supervision of a therapist. The documentation does not support that the requested
services are part of a maintenance program, or that the specialized skill, knowledge and judgment of a qualified
therapist are required to establish, design and/or deliver a program to maintain the patient's current condition or
to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 30 physical therapy visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve 30 physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveContour Next EZ brand diabetic test strips.You asked the Planto pre-approvethe Contour Next EZ test strips. You say that the enrollee needs these strips as they are compatible with the meter they have and they would benefit from continuing with this.The Plandenied your request. The Plansaysthere is no documented medical reason that only the current meter can be used. There is no evidence that the preferred brand would be less effective. A 90 day transitional supply of the non-preferred strips has been approved to allow for a safe transition to a preferred brand meter/test strips.The Plan must follow Medicare rules. Medicare rules say that Plans can limit coverage of DME to certain brands as long as other brands are accessible if medically necessary. The Plan limits coverage to two brands of diabetic testing equipment. In this case, there is no documentation to support that the non-preferred brand is medically necessary. The Plan has coordinated care by approving a temporary supply to assist in the transition to the preferred brand.Therefore, we decided that the Plandoes not haveto pre-approveContour Next EZ brand diabetic test strips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) testing.
You asked the Plan to pre-approve MPI test. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of authorization for this service is correct, because this test is not medically
necessary and would not be expected to alter medical management decisions for the enrollee.
The Plan follows Medicare rules. Medicare rules say that MPI testing is only covered for certain specific
indications when the results would be anticipated to influence medical management decisions.
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 MPI test. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested MPI test. Our physician reviewer found based on
the records the enrollee has some coronary risk but no chest pain, no cardiac physical exam abnormalities, no
ischemic electrocardiographic (EKG) changes, and no abnormal baseline EKG that would preclude accurate
interpretations during exercise. In this circumstance, the enrollee has no documented covered indication for this
test.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MPI test have not been met. Therefore, we decided that the Plan does not have
to pre-approve myocardial perfusion imaging (MPI) testing.
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 for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 29, 2019 with a right hip fracture. She underwent surgical repair on December 30, 2019. She needs contact guard assistance with walking up to 110 feet and varied assistance with activities of daily living. She has no complex issues that require the intensity of services in an IRF. She may benefit from further therapy but does not require an intensive therapy program 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve total knee arthroplasty for the enrollee.
You asked the Plan to pre-approve total knee arthroplasty. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says that the requested services are not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty is covered for certain
indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve total knee arthroplasty. Our reviewer
says that the documentation does support that the requested total knee arthroplasty is medically reasonable and
necessary. Our physician reviewer found the enrollee presents with a history of bilateral knee pain, left greater
than right. The enrollee reports increasing left knee pain with functional limitations in activities of daily living.
Clinical exam findings are consistent with radiographic evidence of bone-on-bone osteoarthritis of the left knee
medial compartment. Reasonable and/or comprehensive treatment, including activity modification,
medications, exercise, and corticosteroid injection, has been documented with failed response. The enrollee has
been cleared by infectious disease, based on a history of prior infections, to proceed with joint replacement
surgery. Records indicated that the surgery would be delayed as the enrollee completed recommended dental
work. The enrollee was to contact the office to schedule surgery when this was completed. Under consideration
is a subsequent request for left total knee arthroplasty. It is reasonable to assume that surgical scheduling has
proceeded based upon completion of the recommended dental work. This enrollee has a diagnosis, condition,
and/or symptoms that meet the Medicare criteria for coverage of total knee arthroplasty. Therefore, this request
for left total knee arthroplasty is medically reasonable and 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 total knee arthroplasty have been met. Therefore, we decided that the Plan has
to pre-approve total knee arthroplasty.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S1015 and S8301 provided on July 1, 2019.You asked the Plan to pay forthe home infusion therapy 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 a covered benefit.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 CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of and payment of these services. Based on this information, we decided that Medicare rules for coverage ofthe home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S1015 and S8301 provided on July 1, 201
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 14, 2019.You asked thePlan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for "the beneficiary".You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 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 services are not medically necessary. Our physician reviewer found the enrollee presented to her primary care physician's office on January 3, 2020 with frequent falls, weakness, leg pain, knee bruising, and urinary frequency. She was diagnosed with a urinary tract infection and is currently at home. She has no complex medical, nursing, or rehabilitation issues that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Shedoes not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services for "the beneficiary".
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide a Dexcom G6 continuous glucose monitoring system.
You asked the Plan to provide Dexcom G6 continuous glucose monitoring system. You say that the Dexcom G6 was not available at the time and the enrollee needs real-time monitoring and alerts. The Plan denied your request. The Plan says that the enrollee was just approved for a FreeStyle Libre on June 21, 2018 and it is essentially the same equipment as the Dexcom CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 provide Dexcom G6 continuous glucose monitoring system. Our physician reviewer found a Dexcom G6 will help to prevent low blood levels the enrollee is having due to hypoglycemic unawareness. The FreeStyle Libre will NOT do this even though is also considered a CGM. Please approve the Dexcom G6. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 continuous glucose monitoring system have been met. Therefore, we decided that the Plan has to provide a Dexcom G6 continuous glucose monitoring system.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient surgery provided on September 5, 2019.You asked the Plan to waive the copaymentforfluoroscopic guided injection. You say that you just had an injection. You say that it is not fair to be charged for a surgery.The Plan denied your request. The Plan says the correct copayment has been applied.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 $250 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay $247.14 which is less than your copayment amount of $250 for fluoroscopic guided injection. The injection you received is considered an outpatient surgery; therefore, the correct copayment has been applied. Fluoroscopic guided injection falls within the outpatient surgery/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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran outpatient surgery provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says there was no truncal swelling or record of a 4 week trial of the basic pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).