Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair.

You asked the Plan to pre-approve power seat elevation feature. You say that you need this feature for safety with transfers.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a power seat elevation feature is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered because it is not primarily medical in nature. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation feature have not been met.Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable hemodynamic monitor (CardioMEMS) (33289, C2624).

You asked the Plan to pre-approve CardioMEMS device. You say that you believe that the CardioMEMSHF system implant is medically reasonable and necessary and warrants prior authorization of coverage and payment for these services.The Plan denied your request. The Plan says this device is considered investigational as there is not have enough proof in medical information or research by specialists that describe the safety, value or effectiveness for this procedure.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS device have not been met.

Therefore, we decided that the Plan does not have to pre-approve implantable hemodynamic monitor (CardioMEMS) (33289, C2624).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp 500MCG/1ML syringe.

You asked the Plan to pre-approve Aranesp 500MCG/1ML syringe. You say that the enrollee needs this drug. The Plan denied your request. The Plan says information from the provider showing iron and hemoglobin levels meeting criteria was not received.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp 500MCG/1ML syringe. Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found Erythropoiesis-stimulating agents (ESAs) such as Aranesp are not indicated for patients receiving myelosuppressive therapy when the anticipated outcome is curative. This patient is being treated for curative intent. In addition, the threshold to start ESAs is 10 and this patient's hemoglobin on last check was 11.3. At this level even if the patient was on an ESA recommendation would be to hold the dose. The service is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp 500MCG/1ML syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp 500MCG/1ML syringe.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI to be provided by an out-of-network provider.

You asked the Plan to pre-approve the MRI. You say that you have seen three neurologists and your current neurologist has diagnosed you with trigeminal neuralgia. The Plan denied your request. The Plan says in-network providers are available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the MRI to be provided by an out-of-network provider.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not have any active, complex medical condition that requires inpatient care and frequent physician oversight.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and increased creatinine and was discharged home with home health services on May 24, 2021. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 the laboratory services rendered on August 27, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not urgent or emergent and rendered by an out-of-area provider without prior authorization.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.

We looked at the file and Medicare rules. The file shows that the services at issue were routine, elective blood work. The services were not for an unforeseen illness or injury and were not emergent in nature. 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 pay for the laboratory services rendered on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) received December 7, 2020.

You asked the Plan to pay for the periodontal maintenance. You say that the Plan has partially covered this service in the past. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

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 pay for the periodontal maintenance (D4910) received December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainers (D6548 x2), and pontic (D6245) provided on February 2, 2021.

You asked the Plan to pay for retainers, and pontic. You say that you want the Plan to pay for the services.The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 pay for retainers (D6548 x2), and pontic (D6245) provided on February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revision of a total hip arthroplasty (27137), arthrotomy with synovectomy (27054) and incision and drainage (26990) provided on September 14, 2020.

You asked the Plan to pay for the surgical services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.

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 coder 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 surgical services. Our reviewer says that CPT code 27137 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation to validate that a revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft was performed on September 14, 2020, therefore this service cannot be verified. Our reviewer found CPT code 27054 does not meet criteria for billing or reimbursement consideration. The medical records do not include sufficient documentation to validate an arthrotomy with synovectomy, hip joint was performed on September 14, 2020, independent of other procedures performed the same day, therefore this service cannot be verified. Additionally, our coder found that CPT code 26990 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that an Incision and drainage, pelvis or hip joint area; deep abscess or hematoma was performed independent of any other service provided on the same day, therefore this service is not eligible for reimbursement as it is inclusive to the more comprehensive/primary procedure performed.

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 surgical services have not been met. Therefore, we decided that the Plan does not have to pay for the revision of a total hip arthroplasty (27137), arthrotomy with synovectomy (27054) and incision and drainage (26990) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 7 simple extractions (D7140) and an
additional 7 surgical extractions (D7210).

You asked the Plan to pre-approve the dental services. You say that you need 14 to 15 teeth to be removed.
You say that you have been on antibiotics for a long time to keep from getting sick from the teeth rotting in
your mouth. The Plan denied your request. The Plan says 6 extractions are covered per year. The Plan also says
that the frequency limit has been reached.

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 and extractions are listed as covered,
the frequency limit has been reached. The record shows that the Plan has already approved extractions for 6
teeth. Therefore, we decided that the Plan does not have to pre-approve an additional 7 simple extractions
(D7140) and an additional 7 surgical extractions (D7210).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are in the hospital and you were told that you needed to go to a rehab hospital. The Plan denied your request. The Plan says that based on Medicare guidelines, your request for approval of an IRF admission does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an infection of the right foot and had amputation of first and second toes on that foot. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. 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 IRF admission and services.
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. The Plan denied your request. The Plan says you do not need an intensive rehab therapy program.

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 physician reviewer found that you were admitted to the acute care hospital for weakness and a urinary tract infection. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic kidney disease. The records show her transferrin saturation is low at 13 percent; therefore, she does not meet the criteria for coverage of Retacrit for iron saturation percentages. The Retacrit is not considered safe and effective or reasonable or medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture.

You asked the Plan to pre-approve the partial denture. You say that you need these dental services since you are not able to eat correctly due to these issues. The Plan denied your request. The Plan says it was decided to approve the crown for tooth #12. However, your dental benefit does not include coverage for partial dentures.

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 upper denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete
lower denture (D5120).

You asked the Plan to pre-approve a complete upper denture, and a complete lower denture. You say that the
services at issue are medically necessary. The Plan denied your request. The Plan says the services are a
covered benefit, but you have exceeded the frequency limit of one every 5 Plan years.

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, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a complete upper denture, and a complete lower denture have not been met. Specifically, the record
shows that you had exceeded the frequency limit prior to this service on May 30, 2019. Therefore, we decided
that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture
(D5120).
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted because of missed dialysis appointments. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee arthroscopy (29876) provided on October 7, 2020.

You asked the Plan to pay for the knee arthroscopy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the service billed.

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 coder 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 knee arthroscopy. Our reviewer says that CPT code 29786 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient to validate that an Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) was performed on October 7, 2020 that was independent of any other procedure performed on the same date of service and meets "medically necessary" indications criteria that allows for a 59 modifier to be added to the procedure when billed. Because there is not sufficient documentation, this procedure is not eligible for separate reimbursement. 

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 knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the knee arthroscopy (29876) provided on October 7, 2020.