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

We decided that the Plan does not have to pre-approve 30 additional non-emergency transportation trips (A0120).
You asked the Plan to pre-approve 30 additional non-emergency transportation trips. You say that you do not have the extra income to take public transportation. The Plan denied your request. The Plan says the requested 30 additional trips would exceed the benefit limit.
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 52 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 30 additional non-emergency transportation trips (A0120).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the enrollee still needs the therapy and without the service the enrollee will end up in long term care. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not meet CMS coverage criteria for an SNF admission. The enrollee does not have daily nursing needs and the enrollee's progress is very slow. Additionally, the enrollee has short-term memory deficits which would preclude the enrollee to retain and gain independence to return to living alone. Medicare requires inpatient rehabilitation facility (IRF) focuses on community discharge and work towards that expectation. The enrollee's progress has been inconsistent and at this point, daily skilled therapy services in an SNF are not justified. Assistance for activities of daily living (ADL) tasks and transfers may be provided by unskilled persons and does not require the hands-on assistance of licensed therapists. This enrollee would be equally well served at an alternative level of care such as a long-term care (LTC) facility with therapy services as needed. Since home discharge is not possible, the enrollee requires a LTC facility placement with intermittent therapies. Hence, the enrollee's needs are at a level of LTC and not an admission to a nursing facility with daily physical therapy (PT), speech and occupational therapy (OT) and nursing 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 SNF care, for the enrollee.
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 LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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. Our physician reviewer found the medical records show the enrollee was admitted after a fall, suffering multiple rib fractures and pneumothorax. The enrollee developed respiratory failure, requiring intubation and cannot be weaned at this time. The enrollee is being treated for delirium and agitation. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that LTACH that are not being provided a the current facility. Medicare criteria for transfer are not met.

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: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve chiropractic services. You say that the care you received from an in-network chiropractor was inadequate, and this is the only provider who can manipulate your spine to gain some relief. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network chiropractor.

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 chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic office visit to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve an orthopedic office visit. You say that you would like to continue to see
this provider. The Plan denied your request. The Plan says there are in-network providers available for these
services.

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 an orthopedic office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal orthosis (L0650) provided to the enrollee on December 10, 2020.
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. The Plan says the documentation indicates that the services are not necessary for treatment of this condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this orthosis have not been met. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a spinal orthosis (L0650) provided to the enrollee on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown, prefabricated post and core, and root canal.
You asked the Plan to pre-approve the crown, prefabricated post and core, and root canal.. You say that you need a root canal due to alternate treatment methods not lasting longer than a year. The Plan denied your request. The Plan says the service is not a covered 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 pre-approve the crown, prefabricated post and core, and root canal.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer.

You asked the Plan to pre-approve these services. You say that you would prefer this procedure over extensive spinal surgery. The Plan denied your request. The Plan says that this service is considered experimental and investigational.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The superion spacer is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your 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 Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the requested item. You say that it is hard to lift your oxygen tanks out of the golf cart. The Plan denied your request. The Plan says you currently have the most appropriate equipment that meets your needs.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that your current device services the same purpose as the requested item. Equipment used for comfort or convenience are not covered. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee has chronic venous insufficiency and lymphedema secondary to chronic deep vein thrombosis. He has completed lymphedema management and met all goals. The Plan denied your request. The Plan says these dressings are non-covered under the surgical dressing benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says the admission to an IRF 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding Modic type changes on the official imaging studies/MRI report (radiologist's impression) of the lumbar spine scan. This represents an apparent unreconciled discrepancy between the radiologist's interpretation and the treating provider's MRI interpretation. Furthermore, there is limited published, large-scale, long-term peer-reviewed literature that shows the requested procedure to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented, or extenuating circumstances noted, to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept procedure at L5-S1 is not medically reasonable or 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 the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve saline water solution (HCPCS A4216).
You asked the Plan to pre-approve the solution. You say that this was covered when the visiting nurse used it during the home health visits. The Plan denied your request. The Plan says this is a non-covered wound care item, because it does not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. Medicare rules say that saline water solution is non-covered. The requested item is not a covered wound care item. Based on this information, we decided that Medicare rules for coverage of the solution have not been met. Therefore, we decided that the Plan does not have to pre-approve saline water solution (HCPCS A4216).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a health club membership.
You asked the Plan to pre-approve a health club membership. The Plan denied your request. The Plan says a health club membership is not a covered benefit under your Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve a health club membership.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a cone beam computed tomography image (D0364) provided on March 19, 2021.
You asked the Plan to pay for a limited oral evaluation, and a cone beam computed tomography image. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says a limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every year. The cone beam computed tomography image is not a covered 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and a cone beam computed tomography image have not been met.
Specifically, the record shows that you had exceeded the frequency limit for the limited oral evaluation prior to this service on January 8, 2021. Additionally, a cone beam computed tomography image is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a cone beam computed tomography image (D0364) provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition formula (B4154).
You asked the Plan to pre-approve enteral nutrition formula. You say that this request is medically necessary due to malnutrition. The Plan denied your request. The Plan says oral supplementation is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve enteral nutrition formula (B4154).
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 IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and confusion. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), prefabricated post and core in addition to crown (D2954), and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided October 12, 2020.
You asked the Plan to pay for the crown, filling and nerve treatment. You say that you would find it emotionally disturbing to lose your tooth. The Plan denied your request. The Plan says these services are not covered under your dental 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 the crown - porcelain/ceramic (D2740), prefabricated post and core in addition to crown (D2954), and endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided October 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on June 4, 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 procedure code 97110 is 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. 

In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on June 4, 2020.