Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you are appealing the denial of custom inserts.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right unilateral medial knee arthroplasty (27446).
You asked the Plan to pre-approve a right unilateral medial knee arthroplasty (27446). You say that the requested right knee arthroplasty is medically necessary. The Plan denied your request. The Plan says the requested right knee arthroplasty is not medically 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 a right unilateral medial knee arthroplasty (27446). Our reviewer says that the requested right knee arthroplasty is not medically necessary. Our physician reviewer found the enrollee is with primary osteoarthritis of the right knee. Based on the records provided, there is no documentation of a recent trial and failure of physical therapy. There is no severe degenerative joint disease on x-ray read by the radiologist. Medicare criteria have not been met in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a right unilateral medial knee arthroplasty (27446) have not been met. Therefore, we decided that the Plan does not have to pre-approve a right unilateral medial knee arthroplasty (27446).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveoxycodone 30mg tablets.You asked the Planto pre-approvethe oxycodone tablets. You say that you feel this should be covered.The Plandenied your request. The Plansaysthis oral drug is not covered by Medicare Part B. Part D coverage must be requested.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 Plandoes not haveto pre-approveoxycodone 30mg tablets.Benefits for the oxycodone tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 3, 2019.
You asked the Plan to pay for the dental service. You say that you had 2 cavities and a tooth that would not survive. You say that the tooth broke while being extracted. You say the provider advised he needed to dig out part of the tooth and stitch the opening. The Plan denied your request. The Plan says surgical extractions are not listed as a covered service.
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 surgical extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 3, 2019.
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 the SNF admission. You say that the enrollee requires skilled care in the SNF setting. The Plan denied your request. The Plan says the enrollee's needs are custodial. There is no need for daily skilled nursing or therapy services.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 90 year old male with prostate cancer, chronic kidney disease on dialysis, stroke and hypertension who was admitted to the hospital. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He had uncomplicated dressings to his right great toe amputation site. He was treated for pain with effect and seen by palliative care. Regarding rehabilitation services, there is no documentation of skilled services or needs. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary 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 admission 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 ophthalmology services (92014, 92015, 92020, 76514, 92025, and 92250) without of network provider.You asked the Plan to pre-approvethese services. You say that you would like to continue to see the physician asyou have been receiving ophthalmology servicesfrom this physician since 2016. The Plan denied your request. The Plan says thisrequested provider is not a networkprovider. There are in-network providers available that can provide the requested 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 pre-approved care.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-approveophthalmology services (92014, 92015, 92020, 76514, 92025, and 92250) with the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2019 by out of
network provider.
You asked the Plan to pay for these services. You say that you self-referred for a second opinion. The Plan
denied your request. The Plan says the services were rendered by an out-of-network provider without 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 has network providers
available who can provide 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 medical services provided on July 16, 2019 by
out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repetitive Transcranial Magnetic Stimulation (rTMS).
You asked the Plan to pre-approve rTMS. You say that the rTMS is medically necessary. The Plan denied your
request. The Plan says rules for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that rTMS is covered only when 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 rTMS. Our reviewer says that coverage
criteria has not been met. Our physician reviewer found it appears that the procedure of Transcranial Magnetic
Stimulation is being used for maintenance rather than acute treatment which is not a covered indication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of rTMS have not been met. Therefore, we decided that the Plan does not have to
pre-approve Repetitive Transcranial Magnetic Stimulation (rTMS).
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bacteremia related to a recent knee infection and suspected osteomyelitis/discitis. The enrollee is receiving a prolonged course of IV antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L0648, L1851-RT-KX, L2397-RT-KX, L1851-LT KX and L2397-LT-KX) provided on July 12, 2019 to July 15, 2019 by True Medical Supplies, LLC.
You asked the Plan to pay for the orthotic devices. You say that the items were medically necessary. The Plan denied your request. The Plan says rules for telehealth have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthotics (L0648, L1851-RT-KX, L2397-RT-KX, L1851-LT KX and L2397-LT-KX) provided on July 12, 2019 to July 15, 2019 by True Medical Supplies, LLC.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath system for the enrollee.
You asked the Plan to pre-approve a bath system. You say that this is medically necessary. The Plan denied your request. The Plan says that the item is non-medical in nature and not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a bath system for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve implantation of the Coflex device for the enrollee.You asked the Planto pre-approve the surgery.. You say that this is medically necessary.The Plandenied your request. The Plan saysthis service is considered to be investigational.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 surgery.. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show spinal instability. The device is not medically 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 surgery. have not been met.Therefore, we decided that the Plandoes not haveto pre-approveimplantation of the Coflex device for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the electrocardiogram (EKG) rendered to The Enrollee by 24/7
Emergency Care on May 22, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says that procedure code 93010 is inclusive to code 99285.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that code 93010 (EKG) is inclusive to code 99285; however,
there are no active NCCI edits that prohibit separate payment of these codes when billed together. Therefore,
we decided that the Plan has to pay for the electrocardiogram (EKG) rendered to The Enrollee by 24/7
Emergency Care on May 22, 2019.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided to the enrollee on
July 3, 2019.
You asked the Plan to pay for the assistant surgeon services. The Plan denied your request. The Plan says this
type of provider is not eligible for reimbursement.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant services is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services
provided to the enrollee on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0652) and garment to use with device (E0667).You asked the Plan to pay fora pneumatic compression device. You say that please see the enclosed documentation supporting medical necessity and coverage under the national coverage determination.The Plan denied your request. The Plan says the enrollee has not completed a four week trial of an E0650 or E0651 as required. Therefore, E0667 is also non-covered when requested in conjunction with the non-approved code E0652.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0652) and garment to use with device (E0667).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on August 14, 2019.
You asked the Plan to pay for the hospital discharge day management. You say that per the physician's notes, the enrollee was put on hospice until they were discharged from the hospital. You also say that the Plan is still responsible for paying for the physician's services. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on August 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve additional mileage. You say that you would like the plan to reconsider your
request. The Plan denied your request. The Plan says per Google maps the total measured distance to your
requested destination from your residence is 54.26 miles, which is over your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way transportation trips per year within a 50 mile limit.
We looked at your request, the records in the case file, and the rules. Your contract with the Plan clearly states
your one-way trips are covered only when they are within a 50 mile limit. In this case, the requested destination
is within 54.26 total measured distance, which is over the 50 mile limit. Therefore, we decided that the Plan
does not have to pre-approve additional mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be provided in the current inpatient hospital.
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 based on the provided medical records the acute care hospital is able to provide all of
the services the enrollee requires. Based on the provided medical records the enrollee is receiving necessary
services and is at an appropriate level of care in the acute care hospital. Continued care at this level is
appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation
facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections (J7321x5).
You asked the Plan to pre-approve the injections. You say that the knee injections have helped in the past. The Plan denied your request. The Plan says the injections are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 the injections. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found there is no documentation of recent physical therapy, NSAID or tylenol trials or a prior intra-articular steroid injection. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections (J7321x5).