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 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 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 has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 9, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services or skilled therapy services. Daily skilled services are not required. This 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).

You asked the Plan to pre-approve the dental services. You say that these services should not have been denied. You say that it is your understanding that the enrollee is paying for enhanced dental coverage. You also say that the enhanced dental coverage should cover the pre-authorized dental services. The Plan denied your request. The Plan says dentures are not listed as covered services.

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. Additionally, the record shows that you the enhanced dental benefit was not effective until April 1, 2021. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthetic leg with advanced foot and ankle.
You asked the Plan to pre-approve prosthetics. You say that the enrollee experienced a physiological change necessitating a new prosthesis as she reports a loose socket and instability on uneven surfaces. The Plan denied your request. The Plan says the denial of authorization for these prosthetic items is correct, because although the enrollee meets criteria for a replacement socket the documentation does not support a need for a complete prosthesis including a new K3 foot.
The plan follows Medicare rules. Medicare rules state that replacement of lower limb prostheses may be covered by Medicare under certain conditions. 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 prosthetics. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested replacement prosthetic items. Our physician reviewer found the requested replacement prosthesis with advanced foot is not medically necessary. The documentation does not support that the enrollee is a K3 functional ambulator. She uses 2 canes to ambulate. There is no evidence of enrollee physiological change or disrepair to her current foot which was approved in 2018. While a new prosthesis may be necessary, the documentation does not support the need for an advanced foot. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic leg with advanced foot and ankle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received December 14, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were told to get a second opinion by your dental provider. The Plan denied your request. The Plan says the requested service is limited to once every three 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are in excess of those covered under this benefit. The Plan has submitted evidence that this date of service exceeds the frequency limitation. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received December 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation provided on July 19, 2020.
You asked the Plan to pay for the air ambulance services. The Plan denied your request. The Plan says air ambulance transportation was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 the air ambulance services. Our reviewer says that the requested air ambulance services are not medically reasonable and necessary. Our physician reviewer found that the documentation did not support that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation provided on July 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging (CPT code 78803), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says that the service is not necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the enrollee's work up thus far, it would be medically appropriate to rule out amyloidosis as a cause of the enrollee's symptoms. To do so, it would be appropriate to utilize a pyro scan as it has demonstrated high sensitivity and specificity for diagnosing cardiac amyloidosis at earlier stages as well as late stages. It has shown to be sufficient for diagnosis of this condition without tissue biopsy.

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 service have been met. Therefore, we decided that the Plan has to pre-approve radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging (CPT code 78803), for the enrollee.

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 the continuation of skilled nursing facility (SNF) care after April 22, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says the rules for the continuation of 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. The member received skilled care and improved, however his function had plateaued, and he did not require any further inpatient skilled rehab services. The member's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of April 22, 2021, the member required custodial services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services you received on October 27, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services you received on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three crowns (D2750) for teeth #5, #19 and #14, retainer crowns (D6750) for teeth #11 and #13, a pontic (D6240) for tooth #12 and core buildup (D2950) for teeth #5 and #19.
You asked the Plan to pre-approve the dental services. You say that you have tooth pain and were told by your dentist that crowns are the only thing that can fix the problem. You do not want to have teeth extracted at your age. The Plan denied your request. The Plan says the crowns cannot be covered because there will still be 8 points in biting contact. The Plan states that extraction of teeth #, #14 and #19 would be reasonable and crowns are not necessary. The Plan also states that fixed bridgework is not covered unless it is required for a cleft palate stabilization or if a removable denture is not feasible. There is no evidence of either of these conditions.
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 some dental 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 the dental services. Our reviewer says that the crowns and the fixed bridge (including retainer crowns and a pontic) are not necessary as requested. Our physician reviewer found that the Plan's supplemental benefit excludes fixed bridgework unless it is required for a cleft palate stabilization or if a removable denture is not feasible. You do not have a cleft palate. The medical record does not indicate that a removable denture is not feasible. The fixed bridge cannot be recommended. The Plan's supplemental benefit also indicates that crowns are not covered if there are 8 points (4 top and 4 bottom) in biting contact. The provided records do not indicate that this is not the case. The elements of the Plan's supplemental coverage criteria are not satisfied. The requested service cannot be recommended based upon the documentation provided. In addition, although the Plan offers a dental benefit in excess of Medicare coverage, the core buildup requested is not among those covered under this benefit and will not be covered under any condition.
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 the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve three crowns (D2750) for teeth #5, #19 and #14, retainer crowns (D6750) for teeth #11 and #13, a pontic (D6240) for tooth #12 and core buildup (D2950) for teeth #5 and #19.
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 member's care needs can be met in the skilled nursing facility setting.
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 surgical treatment of a hip fracture after a fall. The enrollee's medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive assessment of and care planning for patients requiring chronic care management services, domiciliary or rest home visits, and advance care planning provided from January 9, 2020, to February 6, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive assessment and care planning, domiciliary or rest home visits, and advance care planning. You say that these services were provided in an assisted living facility, and were medically necessary. The Plan denied your request. The Plan says these services are not covered when performed by a non-participating provider.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the comprehensive assessment of and care planning for patients requiring chronic care management services, domiciliary or rest home visits, and advance care planning provided from January 9, 2020, to February 6, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 5, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on December 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sprint PNS system.

You asked the Plan to pre-approve Sprint PNS-Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says current peer reviewed data is insufficient to warrant the medical necessity of coverage of PNFS for right knee osteoarthritis.

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 Sprint PNS-Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this would be an experimental/ investigational use of the device. The request 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 Sprint PNS-Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Sprint PNS system.