Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the right knee (64640)You asked the Plan to pre-approve radiofrequency ablation. You say that walking is painful and you do not want knee replacement surgery. The Plan denied your request. The Plan says due to lack of evidence in the peer reviewed literature, peripheral nerve ablation for the treatment of osteoarthritic knee pain is considered 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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of on-going clinical trials and you are not enrolled in a clinical trial.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the right knee (64640)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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.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 is currently undergoing treatment at an acute care hospital (ACH) for pneumonia in the setting of amyotrophic lateral sclerosis (ALS). The enrollee is on a 24hour ventilator and tube feedings at baseline. 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 (LTC) 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 theLTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea group 3 power wheelchair for the enrollee.You asked the Plan to pre-approvethe requested wheelchair. The Plan denied your request. The Plan says there are no notes to show that the enrollee's caregiver cannot adequately propel a manual wheelchair.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrolleesunder certain medical indications.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 requested wheelchair. Our physician reviewer found that the documentation does not reveal a trial of a group 3 power wheelchair to indicate that the patient can safely operate the requested power mobility device. Thereis a detailed right upper extremity neuromuscular exam revealing deficits explaining why the enrollee requires an expandable controller rather than operating the power accessories on the wheelchair through their own individual switches. Without a right upper extremity exam, it is not clear that the enrollee can operate the requested Group 3 power wheelchair independently. The documentation does not indicate that the enrollee has a caregiver who is unable to adequately propel a manual wheelchair, but is available, willing, and has demonstrated that they are able to safely operate the power wheelchair that is requested. Therefore, the requested wheelchair is not medically reasonable and necessary at this time. 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 requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approvea group 3 power wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are 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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable daily skilled nursing or skilled therapy service needs. Your condition 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal maintenance provided on October 2, 2019.You asked the Plan to pay forperiodontal maintenance. You say that denying this treatment is denying the prevention served by the deep cleaning.The Plan denied your request. The Plan says this is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not haveto pay forperiodontal maintenance provided on October 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve the Prolia. You say that the Prolia is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the record does not show that the member tried and failed a trial of zoledronic acid. Our physician reviewer found the documentation does not support that zoledronic acid would likely be less effective or have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain high metal crown (D2750).
You asked the Plan to pre-approve the dental service. You say that you were not adequately informed at the informational meeting when you signed up for the plan coverage for dental. You say that you were told there was an annual maximum of $2,000 for in and out of network dental services. You also say that when you called the plan to confirm coverage on December 26, 2019 you were advised that a crown would be covered under restorative services. The Plan denied your request. The Plan says crowns are not 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 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 porcelain high metal crown (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2), a pontic (D6240), and two retainer crowns (D6750 x2).
You asked the Plan to pre-approve the core buildups, pontic, and retainer crowns. You say that you are on a fixed income. The Plan denied your request. The Plan says Medicare does not cover these services and therefore, these services are not covered by your plan.
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 two core buildups, including any pins when required (D2950 x2), a pontic (D6240), and two retainer crowns (D6750 x2).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medication Aranesp (J0881).You asked the Plan to pre-approvethis medication. You say that the medication is medically necessary.The Plandenied your request. The Plan says the requested drug is subject to step therapy. This requirement encourages you to try the preferred drugRetacrit, which is just as effective. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of the medication Aranesp. Our physician reviewer found the medical records do not indicate that the patient has tried and failed the required drug. Additionally, the medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met.Therefore, we decided that the Plan does not have to pre-approvethe medication Aranesp (J0881).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture (D5110) and a partial mandibular denture (D5214).You asked the Plan to pre-approvethe dental services. You say that you did not have dentures last time. You say that those dentures did not fit you.The Plan denied your request. The Plan says the frequency limit for dentures has been reached.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 and dentures are a covered service, the frequency limit has been exceeded. The record shows that you last received dentures that the Plan paid for onApril 9, 2019.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture (D5110) and a partial mandibular denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (CPT 95999) provided on May 15, 2019.You asked the Plan to pay forthe train of four testing. You say that the service in dispute was medically necessary.The Plan denied your request. The Plan says the service in dispute is considered integral to the primary procedure, neurophysiology monitoring, and therefore is part of a bundled payment.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, train of four testing does not fit the criteria set by CMS, AMA and Insurance Carriers for CPT 95999.  Hence it is inappropriate to bill unlisted neurological or neuromuscular diagnostic procedure code for Train of Four Monitoring. There is no separate code for Train of Four Monitoring. Train of Fourmonitoring is bundled with intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and should not be reported separately.  Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (CPT 95999) provided on May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the wound care provided on October 24, 2019.
You asked the Plan to reduce the copayment for the wound care. You say that there was no surgery provided and you would like the claim reprocessed to either a $10 or $20 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $400 copayment for in-network Medicare-covered outpatient hospital surgery services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $400 copayment for the wound care.
You have been asked to pay a $197.71 copayment for the wound care. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that wound care is considered a surgical procedure.
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 reduce the copayment for the wound care provided on October 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for IRF care 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 as described above.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 thecomplexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF. Medicarecoverage 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5222).
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says immediate partial dentures are not 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 requested dental service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5222).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shoulder surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that until conservative treatment has failed, and the enrollee has a described functional deficit which significantly interferes with ADLs, surgery is not necessary.
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 the surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with persistent right shoulder pain for over one year. Functional limitations have been documented in activities of daily living and work ability as a farmer. Clinical exam findings have documented range of motion and strength deficits and positive orthopedic testing consistent with imaging evidence of supraspinatus and infraspinatus full thickness and retracted tears, mild to moderate glenohumeral osteoarthritis, and impingement morphology. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Under consideration is a request for right shoulder arthroscopic decompression, debridement and rotator cuff repair. Current evidence based medical literature supports the surgical request. There is evidence of pain and significant functional limitations, loss of functional range of motion, loss of functional strength, positive imaging evidence of rotator cuff and impingement pathology, and failure of appropriate conservative treatment. Therefore, this request for right shoulder surgery is medically reasonable and necessary for treatment of this enrollee's medical condition. 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 been met. Therefore, we decided that the Plan has to pre-approve shoulder surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that the enrollee's health will deteriorate without a CGM. The Plan denied your request. The Plan says Medicare criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that a therapeutic CGM is covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump.
We looked at the file and Medicare rules. The submitted information shows that the enrollee is insulin-treated with one daily injection of insulin and does not use a CSII pump. Based on this information, Medicare rules for coverage of a FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on August 12, 2019.You asked the Plan to pay for the hearing aids. You say that you purchased a Lyric Hearing aid and you are requesting reimbursement.The Plan denied your request. The Plan says hearing aids purchased out of network is not covered.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only hearing aid benefit is limited to HEARUSA participating providers only. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for hearing aids purchased on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital observation care services 99220 provided September 29, 2019.
You asked the Plan to pay for observation care services. You say that this enrollee was under observation during this date of service then transferred to inpatient status and you request reconsideration for payment. The Plan denied your request. The Plan says point of service on the 1500 does not match the facility claims on file.
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 billing code 99220 has been billed with the incorrect or missing place of service. Based on this information, we decided that Medicare billing guidelines have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital observation care services 99220 provided September 29, 2019.