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

We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system (CPT code L5781), for the enrollee.

You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your request. The Plan says the item 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 item. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the February 3, 2021 physician exam does not document changes in residual limb volume, edema, excessive moisture. The L5781, Add Lw Limb Pros Residul Limb Vol Mgmt Sys, is not reasonable and necessary and exceeds the patient's medical needs per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k).

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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system (CPT code L5781), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically
necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee was
being treated for spinal stenosis, lumbar region, with neurogenic claudication. He is status post left and right
RFA procedure that was completed on 2/15/21. He notes his pain has improved and states he notices increased
mobility with decreased pain upon flexion as well as extension. Exam reveals height of 70 inches, weight 120
pounds, and BMI of 17.28. There is limited lumbar flexion and extension. Straight leg raise is positive.

However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition as discussed above. FDA indications include implantation of the Superion device at one or two
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no
more than two levels, from L1 to L5.

This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal
stenosis (including the planned level of implantation L4-5.) FDA contraindications include spinal instability,
scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is
imaging evidence of levoscoliosis, and with no documentation of the Cobb angle. There is no discussion
indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. Overall,
there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity
of this request as an exception to guidelines. Therefore, the request for Vertiflex device at L4-5 is not medically
reasonable or 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the laboratory services were provided to the enrollee while the enrollee was in an outpatient rehabilitation setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 3, 2020.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 weakness after a stroke and pressure ulcers. 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, in 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. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received December 30, 2020.
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that the requested service was necessary to fix a crown and implant. The Plan denied your request. The Plan says the requested service exceeds the allowable frequency.
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 in excess of those covered under this benefit. The Plan has submitted evidence that this benefit was exhausted prior to this date of service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulation unit and supplies.
You asked the Plan to pre-approve a neuromuscular electrical stimulation unit and supplies. You say that the requested neuromuscular electrical stimulation unit and supplies is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested neuromuscular electrical stimulation unit and supplies.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a neuromuscular electrical stimulation unit and supplies. Our reviewer says that the enrollee does not meet criteria for the requested neuromuscular electrical stimulation unit and supplies. Our physician reviewer found in this case; the enrollee has postlaminectomy syndrome. The enrollee is non-ambulatory and has not completed 32 physical therapy sessions. The enrollee has spinal cord compression. The enrollee has disuse atrophy with impaired nerve supply to the muscle. 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 a neuromuscular electrical stimulation unit and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a neuromuscular electrical stimulation unit and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 25, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on August 13, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), the prophylaxis 

(D1110), and the unspecified preventive procedure (D1999) received November 12, 2020 received from an out-of-network provider.
You asked the Plan to pay an additional amount for the dental services. You say that you should have a $0 copayment for the requested services. The Plan denied your request. The Plan says the out-of-network provider does not have a contract with the Plan and is allowed to bill the difference of the allowed amount and their billed amount to you.

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 payment is in excess of those covered under this benefit. The Plan has paid 100% of the allowed amount. You are responsible for the difference between the Plan's allowed amount and what was billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the unspecified preventive procedure (D1999) received November 12, 2020 received from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires pulmonary management, wound care, and daily physician visits. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute 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 physician reviewer found that all medically necessary care is being provided in the current acute care setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The health plan has approved ongoing care in the current acute care setting. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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 pre-approve paravertebral facet joint blocks.

You asked the Plan to pre-approve paravertebral facet joint blocks. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show an examination confirming that the enrollee's pain is coming from the facet joint.

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under 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 pre-approve paravertebral facet joint blocks. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested paravertebral facet joint blocks. Our physician reviewer found before performing an interventional procedure a physical examination which details facet loading tests, decreased range of motion and as well as tests to rule radiculopathy is required. Therefore, at this point, the request is deemed not medically reasonable or 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 paravertebral facet joint blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint blocks.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 22, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you thought this was a copayment that should be waived due to the pandemic. You say that you don't want to pay this charge and don't want it to affect your credit. The Plan denied your request. The Plan says the copayment applied 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 $20 copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds. You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan says that the copayment waiver does not include charges for laboratory services. 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 laboratory services provided on September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services after May 10, 2021.
You asked the Plan to pre-approve continued SNF services after May 10, 2021. You say that the enrollee needs SNF services. The Plan denied your request. The Plan says the enrollee has reached maximal benefit from therapy and does not require the skills of a skilled therapist on a daily basis.
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 continued SNF services after May 10, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however her function had plateaued by May 10, 2021 and she did not require any further inpatient skilled rehab services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of May 10, 2021, the member required custodial services. The denial for further inpatient skilled care is upheld.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF services after May 10, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services after May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with intracerebral brain hemorrhage (ICH), currently in IRF. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the acute hospital. The enrollee was at a minimal to maximal assist level for functional mobility. The enrollee required varying assist with activities of daily living. She tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (D6057), and abutment supported porcelain/ceramic crown (D6058) received January 7, 2021.

You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that you spoke to a Plan representative who confirmed the requested procedure was a covered benefit. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 the custom fabricated abutment - includes placement (D6057), and abutment supported porcelain/ceramic crown (D6058) received January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on August 7, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you did not know you would be charged two copayments for this. You say that you cannot afford these copayments. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $160 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $160 copayment for an MRI. The total amount you are being asked to pay is $320 ($160 x 2 MRIs = $320). An MRI falls within the outpatient diagnostic tests/radiological diagnostic 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 copayment for an MRI provided by a participating provider on August 7, 2020.