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

We decided that the Plan does not have to pre-approve complete replacement of the shoulder joint (CPT code 23472), 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 the service is not 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for shoulder replacement surgery not met. There is no documentation of passive range of motion and deltoid function. More information is needed. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve complete replacement of the shoulder joint (CPT code 23472), for the enrollee.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, PICC line infection, and DVT of right upper extremity. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device (22869).

You asked the Plan to pre-approve the Vertiflex device. You say that you hope for a favorable outcome to approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. The Plan denied your request. The Plan says neither Medicare nor the Plan covers this service. Medical studies have not proven that the device is helpful for the treatment of the enrollee's health problem.

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 the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device (22869).
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. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a leg fracture and rib fractures after a fall. Surgery was performed for the leg fracture.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. 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 enrollee will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) and somatosensory testing (95938) provided on June 3, 2020.
You asked the Plan to pay for the needle electromyography and somatosensory testing. You say that you would like reconsideration because the facility does not bill for this service. The Plan denied your request. The Plan says the billed place of service is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 95861 and 95938 are not supported in the record. Specifically, the record indicates that the member was inpatient on the billed date of service. Additionally, as these are technical component codes, payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the needle electromyography and somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) and somatosensory testing (95938) provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings provided from September 8, 2020, to November 16, 2020.
You asked the Plan to pay for the dental services. You say that you have had issues with dizziness and vertigo over the past several years. You say that you have been to different specialists with no resolve. You say that you went to the dentist. You say it was discovered you had mercury fillings placed years ago. You also say that it was medically necessary that you get the mercury fillings removed and new fillings done due to your persistent vertigo. The Plan denied your request. The Plan says the services that you received are dental in nature. The Plan says that the services are not eligible for coverage under the medical benefit. The Plan also says you do not have coverage for any enhanced 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. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Although the Plan offers a dental benefit in excess of Medicare coverage, fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings provided from September 8, 2020, to November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869, 22870).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says the requested procedure is investigational and is not covered.

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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the interspinous spacer device. Open laminectomy is the standard procedure for lumbar spinal stenosis decompression. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that you have seen three different providers that do not work with a neuro-stimulator and you are having a difficult time finding a doctor to help you. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. The Plan also says that the in-network specialist does work with neuro-stimulators.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor and supplies.
You asked the Plan to pre-approve the continuous glucose monitor and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the continuous glucose monitor.
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. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor and supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid.
You asked the Plan to pre-approve Synthroid. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid.
Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chronic care management provided on September 30, 2020.
You asked the Plan to waive the copayment for chronic care management. You say that the nurse did not do anything, and you should not have to pay. The Plan denied your request. The Plan says the copayment 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 $10 copayment for each primary care physician visit for Medicare-covered services. You have been asked to pay a $10 copayment for chronic care management. Chronic care management falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show telehealth services were provided. 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 chronic care management provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you would like approval for these services. 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 office visit to be provided by an out of network (OON) provider.

Please contact the Plan for a list of in-network providers available.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to include multiple teeth extractions, crowns and dentures (CPT code(s): D8010, D6740, D6245, D8740, D6057, D6110, D7210, D6950, D7210 & D6010), to be provided by a provider who does not participate with Medicare.

You asked the Plan to pre-approve the dental services. You say that the Plan should cover these dental services under Medicare approved services and not routine dental since it was a result of an accident. The Plan denied your request. The Plan says when a practitioner opts out of Medicare, Medicare covers no services provided by that practitioner and no Medicare payment can be made to that practitioner directly or indirectly (such as on a capitated basis). The Plan states 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.

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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve dental services to include multiple teeth extractions, crowns and dentures (CPT code(s): D8010, D6740, D6245, D8740, D6057, D6110, D7210, D6950, D7210 & D6010), to be provided by a provider who does not participate with Medicare.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued occupational therapy (OT) sessions.
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 medically necessary outpatient therapy. 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has a history of right shoulder pain and unspecified symptoms of cognitive function and awareness. He has diagnoses of Parkinson's disease, orthostatic hypotension, and generalized muscle weakness. Additional OT is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed to participate in a senior fitness post OT discharge and was instructed on how to work on diaphragmatic breathing. Nursing staff assists with ADLs and functional transfers. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 continued occupational therapy (OT) sessions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 extractions (D7210).

You asked the Plan to pre-approve the dental services. You say that you were advised that you need to have your bottom teeth removed so that you can get a lower denture. You say that you already have an upper denture. You say that all of your bottom teeth are now infected and need to be extracted by an oral surgeon. You also say that you were given pain medication and antibiotics. The Plan denied your request. The Plan says coverage is only allowed for dental services provided by a participating general dentist. The Plan also says that dental services provided by an oral surgeon are not covered.

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, coverage is only allowed for dental services that you receive from a general dentist. Dental services that you receive from an oral surgeon are not covered. Therefore, we decided that the Plan does not have to pre-approve 5 extractions (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.

You asked the Plan to pre-approve the compression stockings. You say that these stockings were approved for you in the past. The Plan denied your request. The Plan says this is not covered for your condition.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by A5631 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.