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

We decided that the Plan does not have to pre-approve SNF care.You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a necessity for the enrollee.The Plan denied your request. The Plan says rules 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 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 that, based on the medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided, the enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. However, daily skilled services are not required. As a practical matter, the enrollee does not require the services on an inpatient basis, only 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 care have not been met.Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery.You asked the Plan to pre-approve Arthrodesis, lumbar (22630), arthrodesis, combined posterior or posterolateral technique, lumbar (22633), Arthrodesis, combined posterior or posterolateral technique, each additional interspace and segment (List separately in addition to code for primary procedure) (22634), Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (22612), Insertion of interbody biomechanical device(s) (22853), Posterior segmental instrumentation (22842). You say that the enrollee needs these procedures for pain relief.The Plan denied your request. The Plan says the enrollee has not had any recent conservative care and no documentation of motor weakness at 3/5 or worse.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 Arthrodesis, lumbar (22630), arthrodesis, combined posterior or posterolateral technique, lumbar (22633), Arthrodesis, combined posterior or posterolateral technique, each additional interspace and segment (List separately in addition to code for primary procedure) (22634), Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (22612), Insertion of interbody biomechanical device(s) (22853), Posterior segmental instrumentation (22842). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative measures to include recent physical therapy for back pain, Surgery is not needed 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 Arthrodesis, lumbar (22630), arthrodesis, combined posterior or posterolateral technique, lumbar (22633), Arthrodesis, combined posterior or posterolateral technique, each additional interspace and segment (List separately in addition to code for primary procedure) (22634), Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (22612), Insertion of interbody biomechanical device(s) (22853), Posterior segmental instrumentation (22842)have not been met.Therefore, we decided that the Plan does not have to pre-approve the spine surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial dentures -resin base (D5212, D5211)You asked the Plan to pre-approve the mandibular partial dentures. You say that you require resin base dentures.The Plan denied your request. The Plan says the requested partial dentures are only eligible for members under the age of 19.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 the mandibular partial dentures -resin base (D5212, D5211).
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-approv eIRF 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 rib fractures, thoracic spinous process fractures, clavicle fracture and occult pneumothorax after a fall. Medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: Surgery
Decision: Favorable

We decided that the Plan has to pay for the debridement services represented by code 11046 provided on December 24, 2020.You asked the Plan to pay for code 11046. You say that the medical records support the billing of CPT code 11046 provided on December 24, 2020.The Plan denied your request. The Plan says that the medical records do not support the billing of CPT code 11046 provided on December 24, 2020.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 11046 is Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).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 code 11046. Our reviewer says that the medical records support the billing of CPT code 11046 provided on December 24, 2020. Our physician reviewer found the enrollee underwent a surgical procedure.  The plan's denial letter omitted a sentence from the operative note.  In relevant part, "[t]his allowed me to refresh the borders of the muscle and subcutaneous tissues . . ."  The operative note describes muscle debridement.  The wound is recorded to be 48 sq cm.  The elements of the coverage criteria are 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 code 11046 have been met.Therefore, we decided that the Plan has to pay for the debridement services represented by code 11046 provided on December 24, 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) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs.Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 4, 2021.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pay for IRF care. You say that IRF care is medically necessary for the enrollee to regain baseline function.The Plan denied your request. The Plan says IRF care is not medically necessary and does not meet criteria for coverage.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 pay for 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 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. 
Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3.You asked the Plan to pre-approve the Gelsyn-3. You say that you would like reconsideration because the requested drug is medically necessary.The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Gelsyn-3. Our reviewer says that the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.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 Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approveGelsyn-3.
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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 the enrollee does not have documented skilled nursing needs.The enrollee does not have documented skilled therapy needs.Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home glucose disposable monitor sensor (A9276).You asked the Plan to pre-approve the home glucose monitor sensor. You say that your doctor utilizes the Bluetooth function so you need it, and no other CGM utilizes it.The Plan denied your request. The Plan says this plan only covers FreeStyle Libre Continuous Glucose Monitors (CGMs).Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan will only cover CGMs that are FreeStyle LibreContinuous Glucose Monitors. The requested provider in this case is not a preferred 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 home glucose disposable monitor sensor (A9276).
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 an IRF admission is medically necessary.The Plan denied your request. The Plan says the request 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 that 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 do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 
Medically necessary services can be provided in a different level of care. 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 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 moderate sedation services coded 99153 provided on February 3, 2021.You asked the Plan to pay for the moderate sedation 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 supported by the documentation.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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3. CPT code 99153 was established as a practice expense-only code meaning there is no work component relative value units (RVU) associated with that service. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on February 3, 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 IRF services are necessary as the enrollee requires 24/7 nursing and daily medical management.The Plan denied your request. The Plan says based on the enrollee's current medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical conditions. An IRF is not supported.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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional one-way trips beyond the 48 one-way trips to locations other than your Primary Care Provider (PCP).You asked the Plan to pre-approve the additional trips. You say that you have medical appointments almost every day. You also say that you would like to go to the gym as well.The Plan denied your request. The Plan says up to 48 one-way trips to non-PCP health care related locations are covered per year. The Plan says that no additional trips beyond the 48 named in the Evidence of Coverage can be approved.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips to other healthcare related locations per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that no additional trips can be added beyond the Plan maximum benefit for coverage of routine transportation.Your request is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve additional one-way trips beyond the 48 one-way trips to locations other than your Primary Care Provider (PCP).