Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and ready for transfer to LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 enrollee continues to receive appropriate acute care services that have not been denied. The enrollee does not require services at the LTACH that he is not receiving in the current acute care 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that RFA is covered for the indications established in the applicable LCD. 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 RFA.
Our reviewer says that the requested RFA is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not had a second confirmatory set of diagnostic medial branch blocks (MBBs). 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve frontal sinus setback, brow contouring, brow lift, hairline advancement, rhinoplasty, septoplasty, angle of mandible reduction, genioplasty, lip lift, fat grafting to lips, tracheal shave. represented by procedure code(s) 31599, 14060, 30410, 30400, 15773, 21139, 21122, 67900, and 21209.
You asked the Plan to pre-approve the facial feminization surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says cosmetic surgery is not a covered benefit for the enrollee's diagnosis.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the facial feminization surgery have not been met. Specifically, cosmetic surgery is not a covered
benefit for gender dysphoria. Therefore, we decided that the Plan does not have to pre-approve frontal sinus
setback, brow contouring, brow lift, hairline advancement, rhinoplasty, septoplasty, angle of mandible
reduction, genioplasty, lip lift, fat grafting to lips, tracheal shave. represented by procedure code(s) 31599,
14060, 30410, 30400, 15773, 21139, 21122, 67900, and 21209.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network surgical center.
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 available from network providers.
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 a referral to an out-of-network surgical center
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent 15 minute increments of deep sedation/general anesthesia and therapeutic parenteral drugs provided on February 17, 2021.
You asked the Plan to pay for the two subsequent 15 minute increments of deep sedation/general anesthesia and therapeutic parenteral drugs. You say that you would like these services to be covered under your out-of-network benefits due to being given misinformation by the Plan. The Plan denied your request. The Plan says your dental maximum has been met and no further benefits are available.
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 Plan offers a $2,000 maximum plan benefit per calendar year. The record shows that you met the annual maximum benefit while reprocessing these claims for the February 3, 2021, and February 17, 2021 dates of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the subsequent 15 minute increments of deep sedation/general anesthesia and therapeutic parenteral drugs provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an out-of-network provider on April 16, 2021.
You asked the Plan to pay for the dental services. You say that this dentist was highly recommended, and you didn't think to check to see if he was in-network. You say that the Plan should consider paying what would normally be paid for in-network. The Plan denied your request. The Plan says the Plan does not cover services from a provide who is not in-network.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided by an out-of-network provider on April 16, 2021
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bilateral upper Blepharoplasty.
You asked the Plan to pre-approve bilateral Blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823). You say that in the morning you have to lift your top eyelids off of your eyes to see properly. The Plan denied your request. The Plan says that the enrollee's Margin Reflex Distance (MRD) is 2.5mm.
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 bilateral Blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has bilateral dermatochalasis. The record indicates that visual function is impaired. The MRD is 2.5., however, taped and un-taped visual field testing is provided that demonstrates there would be functional improvement. The record indicates that the requested surgery is to improve function. The coverage criteria indicate this is an acceptable appeal consideration. The elements of the coverage criteria are satisfied. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral Blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823) have been met. Therefore, we decided that the Plan has to pre-approve bilateral upper Blepharoplasty. 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 skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 have documented skilled nursing or skilled therapy needs. 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. Specifically, medically necessary services can be provided in a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fillings (D2332 x8).
You asked the Plan to pre-approve fillings. You say that the services are necessary. The Plan denied your request. The Plan says services are denied because the provider failed to indicate surfaces for the fillings.
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 fillings 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 fillings. Our reviewer says that the provided records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer found the only records provided are dental radiographic images. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 fillings have not been met. Specifically, the provided records are insufficient to determine the medical necessity and reasonableness of the requested service. Therefore, we decided that the Plan does not have to pre-approve fillings (D2332 x8).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services provided on December 11, 2020.
You asked the Plan to pay for revision of reconstructed breast (e.g., significant removal of tissue, readvancement
and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined
with soft tissue excision in implant-based reconstruction) (19380). You say that the operative report shows this
procedure was done. The Plan denied your request. The Plan says the operative report did not include
documentation of a revision of a reconstructed breast therefore this code cannot be verified.
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 19380 is revision of reconstructed breast (e.g., significant
removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction).
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision
combined with soft tissue excision in implant-based reconstruction) (19380). Our reviewer says that
documentation submitted was reviewed and does not meet criteria. Our reviewer found the documentation
supports reduction of areola, there is a more appropriate code to report for this procedure. Therefore, CPT
19380 would not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of revision of reconstructed breast (e.g., significant removal of tissue, readvancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined
with soft tissue excision in implant-based reconstruction) (19380) have not been met. Therefore, we decided
that the Plan does not have to pay for plastic surgery services provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for a Group 4 Power Wheelchair (K0019, K0017, E2300, K0739).
You asked the Plan to pre-approve the repairs for a Group 4 Power Wheelchair. You say that the repairs are medically necessary and less expensive than a new wheelchair. The Plan denied your request. The Plan says the repairs are non-covered as the type of wheelchair at issue is not eligible for Medicare coverage.
The Plan must follow Medicare rules. Medicare rules say that Group 4 power wheelchairs have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided they will be denied as not reasonable and necessary. We looked at the file and Medicare rules. This type of wheelchair is not eligible for coverage under Medicare. It has features that are not covered. Based on this information, we decided that Medicare rules for coverage of the repairs for a Group 4 Power Wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs for a Group 4 Power Wheelchair (K0019, K0017, E2300, K0739).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64494) provided on January 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (64494) provided on January 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says SNF services are not medically necessary per Medicare coverage criteria.
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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at a minimal assist level with functional mobility including gait to short distances. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
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 enrollee is requesting IRF. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.
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. While the
documentation supports a need for physical and/or occupational therapy, there is no documented need for an
intensive rehabilitation program. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous inpatient psychiatric services.
You asked the Plan to pre-approve continuous inpatient psychiatric services from August 18, 2021 forward.. You say that the enrollee needs additional inpatient psychiatric treatment. The Plan denied your request. The Plan says the records show the enrollee's condition has improved and she is no longer a threat to self or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continuous inpatient psychiatric services from August 18, 2021 forward. Our reviewer says that the health Plan's denial of continued inpatient psychiatric services is appropriate. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 18, 2021 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous inpatient psychiatric services from August 18, 2021 forward. have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous inpatient psychiatric services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology testing provided on April 13, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for the cytopathology testing. You say that the enrollee did not physically go to the
laboratory, so they are not using their out-of-network benefits. The Plan denied your request. The Plan says no
prior authorization was obtained.
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. The record shows the referring provider was not a network provider. 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 cytopathology testing provided on April 13, 2021 by an out-of-network (OON)
provider