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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.

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 device. 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. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture (D5214) provided on October 13, 2020.

You asked the Plan to pay more for the mandibular partial denture. You say that you had gotten approval for full coverage of the denture. The Plan denied your request. The Plan says you had reached your maximum allowed amount of $1,000 for the 2020 calendar year.

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 includes an annual maximum dental benefit of $1,000. The contract clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. The record shows that you met the annual maximum benefit while processing this claim for the October 13, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture (D5214) provided on October 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the polysomnography provided on October 9, 2020.

You asked the Plan to pay for the polysomnography. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on October 2, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the polysomnography provided on October 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 above 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 the enrollee presented to the acute hospital on 02/21/2021 with a fall resulting in a fracture of the shaft of the right fibula. She was observed in the hospital and surgery was not felt necessary and she was transferred to a nursing facility on 02/23/2021. She is non-weight bearing with the right lower extremity and is working with physical and occupational therapy. She hops with a wheeled walker and is contact guard assist for transfers and maximum assist for some activities of daily living (bathing, toileting and lower body dressing). There is no report of any medically unstable conditions. 

Based on the medical records provided there is no documentation that the enrollee requires skilled nursing services or skilled therapy services on a daily basis. The 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 retainer crown - porcelain fused to high noble metal (D6750) and pontic - porcelain fused to high noble metal (D6240).

You asked the Plan to pre-approve a retainer crown - porcelain fused to high noble metal and pontic - porcelain fused to high noble metal. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high noble metal (D6750) and pontic - porcelain fused to high noble metal (D6240).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare states screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found culture with DNA probes for various bacterial and fungal organisms was ordered. There was insufficient support for the DNA probes for pathogen detection in this case. Culture is standard of care in this situation along with urinalysis. Only if confusing results were found from these first line testing methods would DNA probe testing be supported in active infection. Therefore, this request for genetic screening testing will be considered not medically necessary based on the documentation provided.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is 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 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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Medicare coverage criteria are not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of a modality to 1 or more areas; traction, mechanical (CPT Code 97012), evaluation and management (99213), chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions (98943) provided to the enrollee by a non-participating provider.

You asked the Plan to pay for the services. You say that you were informed there were no visit maximums for chiropractic services. The Plan denied your request. The Plan says these services are not covered by the Plan or Medicare when billed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. The enrollee's EOC clearly states that only routine manual manipulation of the spine to correct subluxation is covered. The CMS guidelines state that all other services billed by a chiropractor are not covered. The servicing provider is a non-contracted chiropractor. The Health Plan correctly paid for the manipulation (CPT 98941) and denied (99213, 98943, 97012) as these services are statutorily excluded when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for application of a modality to 1 or more areas; traction, mechanical (CPT Code 97012), evaluation and management (99213), chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions (98943) provided to the enrollee by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mild percutaneous image guided lumbar decompression (PILD).

You asked the Plan to pre-approve the mild PILD. You say that if the doctor's office is not qualified to perform the procedure then you should be referred to a doctor who is qualified to perform the procedure. The Plan denied your request. The Plan says the requested procedure is only covered when it is being provided as part of a Medicare approved clinical trial. There is no indication that the service requested is part of a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mild PILD have not been met. Therefore, we decided that the Plan does not have to pre-approve mild percutaneous image guided lumbar decompression (PILD).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that the requested home health services are medically necessary. 

The Plan denied your request. The Plan says the enrollee does not meet criteria for home health services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer says that the enrollee does not meet criteria for home health services. Our physician reviewer found the enrollee is with a history of an infection in a right knee arthroplasty. Home health physical therapy services have been requested. At issue in this case is whether the home health services are eligible for coverage under Medicare guidelines. The health plan denied coverage for the home health services stating that the available medical records do not support necessity of the services as defined by Medicare criteria as the records do not document that she is home bound. The plan states that outpatient physical therapy (and transportation) can be arranged for her. 

Based on the medical records provided there is no documentation that skilled home therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee does require physical therapy services but these can be provided in the outpatient setting and the health plan has stated they will provide transportation services for her for the outpatient treatment as defined by her benefits. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is 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 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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulse oximeter (E0445).

You asked the Plan to pre-approve the pulse oximeter. You say that you require the device for underlying diabetic conditions. The Plan denied your request. The Plan says you do not have respiratory problems documented in the file.

The Plan must follow Medicare rules. Medicare rules say that Pulse Oximeters are limited to enrollees with respiratory conditions that affect their oxygenation levels. The enrollee does not have any respiratory problems documented. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pulse oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve a pulse oximeter (E0445).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's illness is not complex enough to require daily physician management and require specialized nursing services that are only available in an LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and emergency care.

You asked the Plan to waive the copayments for an inpatient hospital stay and emergency care. You say that you disagree with the charges because you were given bad information that resulted in the hospital stay. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $225 copayment for days 1-3 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $65 copayment for emergency care.

You had an inpatient hospital stay. Therefore, you are responsible to pay a $225 copayment for days 1-2. $225 (copayment) x 2 (inpatient days) = $450.

You received emergency care. Therefore, you are responsible to pay the $65 copayment.

The total amount you owe is: $515.

You have been asked to pay the total copayment amount of $515 for an inpatient hospital stay and emergency care. An inpatient hospital stay falls within the inpatient hospital care benefit category. Emergency care falls within the emergency 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 copayments for an inpatient hospital stay and emergency care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6532.

You asked the Plan to pre-approve the compression stockings. You say that the compression stockings were prescribed to combat the intermittent swelling that you experience on your feet. The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6532 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6532.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is 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 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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Medicare coverage criteria are not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted provides no additional information that justifies this request.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the monitor would not be considered therapeutic. There is no indication that the enrollee requires frequent adjustments in insulin. Glucose is being tested twice daily. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.