Persius/hicric huggingface dataset:
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 therapy and nursing needs are being met in the skilled nursing facility.

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 bilateral critical limb ischemia
managed with aorto bi femoral bypass grafting and bilateral lower extremity fasciotomies. 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 you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 24, 2021, through January 25, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 copayment each day one through seven for inpatient hospital care. 

You have been asked to pay a $310 copayment each day one through seven for inpatient hospital care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 24, 2021, through January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vantas.

You asked the Plan to pre-approve Vantas. You say that your health history supports the need for the requested drug. You say that this drug was paid for by your last insurance company. The Plan denied your request. The Plan says this drug falls under Part D coverage, but the enrollee has no Part D pharmacy benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Vantas.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on January 4, 2021.

You asked the Plan to pay for the subsequent hospital care 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 payable.

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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 

We find that CPT code 99232 is not supported in the medical record. Specifically, the enrollee was seen in hospital evaluation on January 4, 2021. The submitted documentation supports one unit of this code, which was previously approved. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on January 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan.

You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan. Our reviewer says that the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of one year of chronic right leg pain and recent worsening of buttock and right foot pain with numbness and weakness. Straight leg raise positive, sensation and reflexes equal and symmetrical. Normal gait and station, but impaired hell and toe walking. X-ray spine showed facet arthropathy, same as prior imaging without significant change. The provided progress notes did not reveal any recent attempts with physical therapy, non-steroidal anti-inflammatory drugs, or other conservative first line treatment options for his acute on chronic lumbar radiculopathy. There were no signs or symptoms suggestive of a red flag diagnosis to justify bypassing this trial. Therefore, the enrollee does not meet criteria for the requested 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 an MRI scan. have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received January 14,
2021.

You asked the Plan to pay for the crown. You say that obtaining approval for the requested services took a long
time you would like the Plan to pay for them. The Plan denied your request. The Plan says the requested
service exceeds the frequency limitation of your 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 in
excess of those covered under this benefit. The Plan limits coverage of crowns to one per calendar year. The
Plan has submitted evidence that you had exhausted this benefit on this date of service. Therefore, we decided
that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received January 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 31, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the visit was authorized. The Plan denied your request. The Plan says the services were rendered by a non-network provider, and the enrollee was referred by a non-participating nursing facility.

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 items/services at issue in this appeal. 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 subsequent nursing facility care provided on December 31, 2020 by an OON provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve duplex scans of extremity veins for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the reason for a repeat study has not been clearly stated in either the provided clinical documentation or the appeal letter.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are 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 scan. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the medical necessity of the venous duplex. The enrollee is status-post radiofrequency ablation of the right greater saphenous vein on April 27, 2021. A follow-up duplex shortly following greater saphenous vein ablation is appropriate and medically necessary. Even the health plan acknowledges that the duplex performed to assess the efficacy of the procedure performed 2 days earlier would meet medical policy criteria for coverage. 

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 scan have been met. Therefore, we decided that the Plan has to pre-approve duplex scans of extremity veins 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a therapeutic continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from August 5, 2020, through
September 17, 2020.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.

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
physical therapy services. 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 physical therapy provided from August 5, 2020,
through September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #15.

You asked the Plan to pre-approve the crown. You say that this tooth is still very functional and does not have significant mobility but has a weak structure. The tooth has had previous root canal treatment and the enrollee would prefer to save the molar. The Plan denied your request. The Plan says there is less than 50% bone support and there is a clinically unacceptable root canal fill and radiolucency on this tooth. Criteria are not met.

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 the crown when the services are medically necessary and reasonable. In general, criteria for crowns will be met only for permanent teeth needing multi-surface restorations where other restorative materials have a poor prognosis. Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma and should involve four or more surfaces and two or more cusps. The tooth should be filled sufficiently close to the radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the canal that limits the ability to fill the canal to the apex. The filling must be properly condensed/obturated. The filling material should not extend excessively beyond the apex.

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 crown. Our reviewer says that the criteria are not met. Our physician reviewer found that the tooth in question presents with over 65% of the supporting bone missing, and it has had previous endodontic treatment. The endodontic fill is very short of the apex of the tooth and appears to be poorly condensed. The tooth presents with an existing two surface restoration and prior endodontic treatment as well as severe periodontal disease. There may be a small periapical lesion seen as well, though the x-ray is not clear in the apical region. The provider noted that the tooth has minimal mobility; however, the poor bone support in combination with an unacceptable root canal fill leaves the tooth with a very poor long-term prognosis.

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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #15.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network
provider.

You asked the Plan to pre-approve out-of-network dialysis services. You say that you want to move your
dialysis treatments and you don't understand why this location will not accept this insurance. The Plan denied
your request. The Plan says the requested services are available in-network.

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
dialysis services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an intrauterine device (IUD).

You asked the Plan to pre-approve insertion of IUD. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically 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 insertion of IUD. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you had postmenopausal bleeding. No hyperplasia or malignancy was found. A possible endometrial polyp was removed. There is a known fibroid. The pathology did not show any concern for proliferative endometrium that could lead to endometrial hyperplasia in the future. Therefore, there is no medical reason for a levonorgestrel IUD to be placed at this time. There is no reason to treat atrophic endometrium with a levonorgestrel IUD. Your fibroid should be inactive and decrease in size in the postmenopausal period. Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. The documentation does not show that this service is being requested to treat a specific illness/injury. Based on this information, we decided that Medicare rules for coverage of insertion of IUD have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an intrauterine device (IUD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 24, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 24, 2020.