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

We decided that the Plan does not have to pay for the x-ray exam (74019) provided by an out of network (OON) provider.

You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says they do not cover out of network services, except in limited circumstances. The services provided were not urgent or pre-approved.

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 had network providers available who could have provided 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 x-ray exam (74019) provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary.
The Plan denied your request. The Plan says the enrollee can continue care at current level facility.

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 there are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan.

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. Specifically, medically necessary
services are being obtained at the member's current level of care. This means admission to an LTACH is not
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve LTACH
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6752, D6242).

You asked the Plan to pre-approve the services. You say that this is medically necessary. 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 have to pre-approve dental services (D6752, D6242).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 80 ostomy pouches a month.

You asked the Plan to pre-approve 80 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each (A5056). You say that the enrollee needs 80 ostomy pouches a month. The Plan denied your request. The Plan says they will approve 60 ostomy pouches a month but not 80 a month.

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 80 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each (A5056). Our reviewer says that 20 more pouches a month is not supported in the records. Our physician reviewer found the provided records did not sufficiently support the request for extra pouches than previously received. Therefore, the remaining 20 pouches per month will be considered not medically necessary.

We looked at this physician's review, the file, and Medicare rules. The usual quantity is 40 per month. Based on this information, we decided that Medicare rules for coverage of 80 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each (A5056) have not been met. Therefore, we decided that the Plan does not have to pre-approve 80 ostomy pouches a month.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services (DRG 871) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment of DRG 872 is supported rather than DRG 871.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 871 is defined as "SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC."

In this case, you billed the services provided with DRG 871. 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 services. Our reviewer says that the services at issue in this were not supported by the medical records. Our physician reviewer found the enrollee is a 90 year old male who presented to the emergency department with altered mental status. He was diagnosed with urinary tract infection (UTI) and sepsis. Vitals included tachypnea and tachycardia and fever. He was also noted to have leukocytosis and acute kidney injury. Encephalopathy was diagnosed likely related to UTI. There was evidence suggestive of sepsis for this enrollee with encephalopathy, acute kidney injury, and abnormal vitals, however, it did not appear to be severe or with major complication or comorbidity, therefore, the DRG 872 appears to be most appropriate here.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 871." Therefore, we decided that the Plan does not have to pay for inpatient hospital services (DRG 871) provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you will not be able to fully recover without the assistance and aid provided in an IRF. The Plan denied your request. The Plan says this request is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a Vertiflex Superion device (22869 and 22870).

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the device is medically necessary. The Plan denied your request. The Plan says that the devise is experimental.

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 Vertiflex Superion device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the superion interspinous spacer device has been FDA-approved for treating this patient's condition and has sufficient supportive evidence to justify use in this specific case as it would be lower risk than other procedures.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device have been met. Specifically, there is supporting documentation indicating this patient would benefit from this service. This means the service is medically necessary and reasonable. Therefore, we decided that the Plan has to pre-approve a Vertiflex Superion device (22869 and 22870).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says alternate settings can be requested, such as skilled nursing facility, outpatient setting, or
home health care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for cellulitis of left leg stump and had left above the knee amputation. Medical problems are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of nerves innervating the sacroiliac SI joint with image guidance (64625).

You asked the Plan to pre-approve RFA. You say that the service is medically necessary. The Plan denied your request. The Plan says clinical value and effectiveness of RFA of SI joint in the setting of chronic low back pain and SI joint pain has not been demonstrated in peer-reviewed literature.

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 RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no information provided regarding your prior SI ablation procedure, how long it lasted, to what degree, and if it led to improvement in overall function to help justify repeating this procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Specifically, there was not enough information provided to determine the medical necessity of this service, and therefore, cannot be covered. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of nerves innervating the sacroiliac SI joint with image guidance (64625).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not require skilled nursing or therapy services on a daily basis. 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. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, lumbar spine; without contrast material (CPT code 72131) for the enrollee.

You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our physician reviewer found based on the provided documentation, there is insufficient support for the CT scan. No radiculopathy noted, no signs or symptoms suggestive of a red flag diagnosis warranting imaging of any kind at this time. Therefore, this request for CT lumbar spine will be considered not medically 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, lumbar spine; without contrast material (CPT code 72131) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic on tooth #20 and #21, and
crowns on tooth #19 and #22.

You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says a partial denture is the most cost-effective treatment the replace more than
one missing tooth in the same part of the mouth.

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 dental services. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found tooth #19 has an existing crown in place that is reported to be defective. Tooth #22 appears
unrestored and would be an acceptable abutment tooth. The Plan states that "The placement of a fixed
prosthetic appliance will only be considered for those exceptional cases where there is a documented physical
or neurological disorder that would preclude placement of a removable prosthesis." In this instance, there has
been no documentation of any physical or neurological deficits that would make the use of a removable
prosthesis reasonable. Although the requested bridge is a reasonable alternative treatment plan, the criteria
preclude coverage unless documentation of a physical or neurological deficit is present. If the crown on #19 is
defective, it could be replaced, and a removable appliance used to replace the two missing premolars. Given the
plan provisions, there would be no medical necessity for the requested procedures.

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 dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve a porcelain/ceramic pontic on tooth #20 and #21, and crowns on tooth #19 and #22.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing visits.

You asked the Plan to pre-approve additional home health skilled nursing visits. You say that the care to be provided is medically necessary. The Plan denied your request. The Plan says the additional home health skilled nursing visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional home health skilled nursing visits. Our reviewer says that the additional home health skilled nursing visits are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The available records document two wounds that are 0x0x0 cm in dimension and reported to be closed and a third ulcer for which no dimensions are provided. The therapy orders for the third wound do not include any skilled services. No other skilled nursing services appear to be indicated based on the available records.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.

You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration because these compression wraps are medically necessary for the member to facilitate wound healing. The Plan denied your request. The Plan says there is no documentation of how many wounds, wound size, drainage amount and type, and how often the dressings are changed.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

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 for the compression stockings. Our physician reviewer found that there is insufficient support made to show this patient meets the criteria for the compression wraps. The provided notes did not describe the dimensions, quality, and number of wounds present and no record of recent debridement was noted.

We looked at this physician's review, the file and Medicare rules. Based on this information, we have decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.

You asked the Plan to pay for a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.