Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 13, 2021, to January 15, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing care needs could have been provided in an alternative level of care. The Plan also says that there were no contraindications documented for discharge after the first hospital day. The Plan also says that the enrollee's care did not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation supports that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Therefore, the reviewer found that the acute inpatient hospital care meets the criteria for coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, the record shows that the admitting provider expected the enrollee's necessary hospital care to span 2 midnights. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 13, 2021, to January 15, 2021.

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: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve additional skilled nursing services of a registered nurse in the home health setting (G0299).
You asked the Plan to pre-approve skilled nursing services in the home health setting. You say that the enrollee has not yet met all the goals of skilled nursing services. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Therefore, we decided that the Plan has to pre-approve additional skilled nursing services of a registered nurse in the home health setting (G0299).
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 pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has failed conservative approaches to treatment at this time. The Plan denied your request. The Plan says the services are considered experimental and 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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial upper denture (D5820), the surgical extractions (D7210 x 3), and the bone replacement grafts (D4623 x 3) provided from February 16, 2021, to February 24, 2021.
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that you could see any dentist of your choice. You say that there was no mention of needing to use a Medicare approved provider. You also say that you feel that you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case was excluded from participating in federal programs at the time these services were provided.
The Plan must follow Medicare rules. The rules say that no payment is made to any business or facility, e.g., a hospital, that submits claims for payment of items or services provided, ordered, prescribed, or referred by an excluded party. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the record shows that the provider in this case is excluded from Medicare. The record also shows that you were told before the appointment that this provider did not accept Medicare. Therefore, we decided that the Plan does not have to pay for the interim partial upper denture (D5820), the surgical extractions (D7210 x 3), and the bone replacement grafts (D4623 x 3) provided from February 16, 2021, to February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravitreal injection provided on May 12, 2020 by an out-of-network provider.

You asked the Plan to pay for Injection, aflibercept, 1 mg (J0178). You say that the provider was not aware the code was not added to the authorization. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for the item. Therefore, we decided that the Plan does not have to pay for the intravitreal injection provided on May 12, 2020 by an out-of-network 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 a skilled nursing facility is not the appropriate level of care at this time due to the complexity of the enrollee's needs and the frequency of complications he has suffered. The Plan denied your request. The Plan says the records do not show the enrollee is medically stable to leave the acute care 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 the medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 

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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met, and the enrollee can safely receive the necessary care in another setting.

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 that 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 does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery: left L4-5 transforaminal lumbar interbody fusion and L2-3 discectomy (CPT code(s): 22633, 63047, and 63030), for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee has not had conservative treatment, does not have signs of nerve root compression directly visualized on the magnetic resonance imaging. The Plan denied your request. The Plan says the submitted documentation does not indicate the enrollee completed conservative treatment in the last six (6) months, the physical exam done does not indicate findings of nerve root compression and the enrollee recently quit smoking on August 1, 2021.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for lumbar fusion not met. More conservative measures are needed to include a recent and adequate trial of physical therapy (PT). The enrollee must stop smoking for at least twelve (12) weeks prior to fusion. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve back surgery: left L4-5 transforaminal lumbar interbody fusion and L2-3 discectomy (CPT code(s): 22633, 63047, and 63030), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 physical therapy visits.
You asked the Plan to pre-approve 12 physical therapy visits. You say that you are still in pain. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 12 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist continue to be required to safely and effectively provide treatment. The Plan has authorized sufficient additional therapy to ensure you are competent in a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) (CPT code 15733) provided to the enrollee on September 17, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 physician reviewer found the record indicates that the enrollee underwent a procedure on September 17, 2020. The provided operative note does not describe the utilization of a myocutaneous, or fasciocutaneous flap based upon a named vascular pedicle of either buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, or levator scapulae. The elements of the coverage rule are not satisfied. The requested service is not recommended. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) (CPT code 15733) provided to the enrollee on September 17, 2020.
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 enrollee needs a LTACH admission immediately. The Plan denied your request. The Plan says the services the enrollee needs can be provided in another setting.
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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide coverage for the periodic oral evaluation - established patient (D0120) provided April 19, 2021.

You asked the Plan to provide coverage for the periodic oral exam. You say that you haven't submitted an appeal since 2017. The Plan denied your request. The Plan says that you have exceeded frequency limits for this service because you had a comprehensive oral exam in February 2021.

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. The Plan covers the periodic oral exam once every six months. 

We looked at the file, and Medicare rules. The Plan denied coverage because coverage was previously provided for a comprehensive oral exam on February 8, 2021. The EOC is not clear that a comprehensive oral exam would count towards frequency limit for periodic oral exams as the service limit for each service is listed separately. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam have been met. Therefore, we decided that the Plan has to provide coverage for the periodic oral evaluation - established patient (D0120) provided April 19, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code 81479) provided to the enrollee on April 22, 2021, by an out-of-network provider.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 laboratory testing (CPT code 81479) provided to the enrollee on April 22, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Foundation One genetic testing provided on December 22, 2020.
You asked the Plan to pay for the Foundation One genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Foundation One genetic testing is only covered for certain 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 pay for the Foundation One genetic testing. Our reviewer says that the documentation does not support that the services rendered were medically necessary. Our physician reviewer found the enrollee has recurrent vulvar cancer, senile dementia Severe mental deterioration in old age), chronic (continuous) pain, urinary incontinence (uncontrolled leaking of urine) and frequent urinary tract infections. There was no indication that the provider was seeking further treatment options, palliative care was noted along with a referral to Hospice. While the enrollee has a diagnosis/condition that meets criteria for the rendered services, the services rendered were 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 Foundation One genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the Foundation One genetic testing provided on December 22, 2020.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.

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 physician reviewer found that the enrollee was admitted to the current acute care hospital for acute respiratory failure, pneumonia, urinary tract infection and folliculitis. He was treated with intravenous antibiotics and mechanical ventilation. He appears to be worsening again and requires additional short-term acute care services to stabilize him, which can be safely performed at the current facility. He does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as there is no notable advantage to transfer 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.