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

We decided that the Plan does not have to pre-approve YAG laser vitreolysis.
You asked the Plan to pre-approve the eye procedure. The Plan denied your request. The Plan says this 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 the eye procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary. Our physician reviewer found that the current medical literature suggests that YAG laser vitreolysis may be a viable option for the symptomatic relief of selected patients with bothersome complaints due to vitreous opacities. However, results are conflicting, and potentially sight-threatening complications have been reported. The documentation in the case file does not support that YAG laser vitreolysis would likely improve the enrollee's visual acuity. The procedure is not medically reasonable and necessary for the enrollee 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 the eye procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve YAG laser vitreolysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ostomy pouch, drain high output (A4412) and ostomy skin barrier, with flange (A4414) provided January 20, 2021.
You asked the Plan to pay for the ostomy supplies. You say that these items have been paid by Medicare in the past. Also please note that the physician and the facility are in network with the Plan. The Plan denied your request. The Plan says payment for these items are included in Part A SNF payment as the enrollee was in a covered Part A stay.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the ostomy supplies were used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the ostomy pouch, drain high output (A4412) and ostomy skin barrier, with flange (A4414) provided January 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you have a concussion and need the SNF level of care. The Plan denied your request. The Plan says your request for approval of admission to skilled nursing facility does not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. 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 the SNF admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is reported as having suspicion for multiple myeloma but no serum protein electrophoresis (SPEP) or urine protein electrophoresis (UPEP) testing is provided. The labs only show a mildly decreased estimated glomerular filtration rate (EGFR). The criteria for the PET scan are not met and the services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an upper partial denture (D5225) provided on March 11, 2021.
You asked the Plan to pay for an upper partial denture. You say that you were told the service would be covered. The Plan denied your request. The Plan says the service at issue 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 pay for an upper partial denture (D5225) provided on March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you believe the enrollee meets the medical necessity criteria and requires an inpatient stay to manage their needs for nursing and medical management. The Plan denied your request. The Plan says the records do not show that the enrollee needs to be seen by a rehabilitation doctor 3 or more times per week. The Plan also says that the enrollee does not need an intensive team for their care and can safely receive the services they need in other settings.
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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional wheelchair accessories (E2201, E2611).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these requested items exceed your medical need. The documentation is not clear on why you are unable to use the group 3 power wheelchair that was approved in 2019. The requested accessories do not appear to be medically necessary, as the manual wheelchair itself is not medically necessary.
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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional wheelchair accessories (E2201, E2611).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a cone beam computed tomography image (D0380) provided on April 16, 2021.
You asked the Plan to pay for a limited oral evaluation, and a cone beam computed tomography image. You say that the services were necessary, and you want the Plan to pay for them. The Plan denied your request. The Plan says the limited oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every calendar year. The cone beam computed tomography image 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and a cone beam computed tomography image have not been met.
Specifically, the record shows that you had exceeded the frequency limit for oral evaluations prior to this service. Additionally, the cone beam computed tomography image is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a cone beam computed tomography image (D0380) provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an office visit and a cystourethroscopy
provided from February 1, 2021, to February 22, 2021.
You asked the Plan to waive the copayments for an office visit and a cystourethroscopy. You say that you
already paid the cost-sharing charges and disagree with the statement you received. 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 $25
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $275
copayment for outpatient hospital services.
You had an office visit on February 1, 2021. Therefore, you are responsible to pay the $25 copayment.
You received a cystourethroscopy at an outpatient hospital facility on February 22, 2021. Therefore, you are
responsible to pay the $275 copayment.
The total amount you owe is: $300.
You have been asked to pay the total copayment amount of $300 for an office visit and a cystourethroscopy.
An office visit falls within the physician/practitioner services, including doctor's office visits benefit category.
A cystourethroscopy falls within the outpatient hospital services 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 office visit and a cystourethroscopy provided from February 1, 2021, to
February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on February 24, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, exams including periodontal exam and comprehensive oral evaluation, are limited to one procedure code every three calendar years. The record shows that you received a comprehensive oral evaluation on August 9, 2019 and your periodontal exam and comprehensive oral evaluation benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications established in the applicable LCD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested facet joint injections are not medically reasonable and necessary. Our physician reviewer found that facet joint procedures after anterior lumbar interbody fusion (ALIF) are not reasonable or medically necessary. The requested facet joint injections are not medically reasonable or necessary according to the coverage criteria established in the LCD.
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 facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve K3 knee and foot (L5814, L5845, L5850, L5848, L5981, L59856).
You asked the Plan to pre-approve K3 knee and foot. You say that the enrollee has not been able to be as active as he wanted to be due to the lack of stability his old knee provided. The Plan denied your request. The Plan says the request for K3 knee and foot does not meet Medicare criteria as reasonable and 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 K3 knee and foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not show current ability to perform at a K3 level to justify this request. There was no specific description documented explaining why the enrollee would be most appropriate at this time for a K3 prosthesis over a K2 prosthesis. Therefore, this request for such 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 K3 knee and foot have not been met. Therefore, we decided that the Plan does not have to pre-approve K3 knee and foot (L5814, L5845, L5850, L5848, L5981, L59856).
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 this enrollee requires care at an LTACH level in order to achieve a safe and sustainable discharge home. The Plan denied your request. The Plan says criteria for an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. An LTACH would provide no additional services.
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 appears to be improving and requires only short-term additional acute care services which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not a
Medicare certified provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the services provided on March 18,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service you received on April 21, 2021.
You asked the Plan to waive the copayment for the ambulance service. You say that you would like to appeal this charge. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 ambulance services. You have been asked to pay a $225 copayment for the ambulance service. 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 copayment for the ambulance service you received on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397) provided on April 14, 2021.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 a knee brace and a suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, that there is insufficient documentation of an appropriate evaluation of the enrollee, and that there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee brace and a suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397) provided on April 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services rendered on December 15, 2020 to December 19, 2020.
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 procedure code G0299 is not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. We looked at the file and Medicare rules. Billed procedure code G0299 (direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes) has a status indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services rendered on December 15, 2020 to December 19, 2020.