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

We decided that the Plan does not have to pre-approve Hymovis injections, bilateral ankles and shoulders.
You asked the Plan to pre-approve Hymovis injection 1 mg, Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg (J7322). You say that patients were not advised of the Plan's changed policy limiting the injections to the knee only. The Plan denied your request. The Plan says Medicare only covers hyaluronan injections into the knee.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Hymovis injection 1 mg, Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg (J7322). Our reviewer says that the requested use of Hymovis is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found the FDA has approved the use of Hymovis for treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and to simple analgesics. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis injection 1 mg, Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg (J7322) have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis injections, bilateral ankles and shoulders.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 21, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 office visit provided on December 21, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 7, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to go to a new dentist, and feel they should have advised you that this service would not be covered. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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 April 25, 2019 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 January 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee arthroplasty with inpatient services.

You asked the Plan to pre-approve total knee arthroplasty with inpatient services. You say that the requested total knee arthroplasty with inpatient services is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested total knee arthroplasty with inpatient services.

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 total knee arthroplasty with inpatient services. Our reviewer says that the enrollee does not meet criteria for the requested total knee arthroplasty with inpatient services. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measure. 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 left total knee arthroplasty (27486, 27487) and inpatient hospital stay 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 total knee arthroplasty with inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty with inpatient services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after June 17, 2021.
You asked the Plan to pre-approve the continuation of SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare coverage criteria for continuation of SNF services.
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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective; the enrollee received oral medications. The enrollee had stable vital signs. The enrollee's lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy (PT) in the SNF. By the dates in question, the enrollee was at supervision/touch assist to moderate assist level with functional mobility. He had 'poor awareness' of his 50% weight bearing status. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the 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 the continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from September 16, 2020,
through September 30, 2020.

You asked the Plan to pay for the physician's services. You say that the physician has no knowledge of the
authorization status for the hospital stay. The Plan denied your request. The Plan says authorization was
required. The inpatient service was not approved per authorization 0010141915 on file.

The Plan contract says the enrollee must get approval in advance from the Plan before the enrollee is admitted
to the facility or the stay will not be covered.

We looked at the file and the Plan's rules. The file shows that there was not an approved authorization from the
Plan for the inpatient services. Therefore, we decided that the Plan does not have to pay for physician's services
provided from September 16, 2020, through September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on February 12, 2021.
You asked the Plan to pay for foot orthotics. You say that you cannot walk without orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0120, D01110) received January 19, 2021.

You asked the Plan to pay for the dental services. You say that you were not informed of a waiting period before dental coverage became effective. The Plan denied your request. The Plan says your dental coverage was not in effect on this date of service. Your dental coverage became effective February 2, 2021.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The Plan has submitted evidence that your dental coverage was not effective on this date of service. Therefore, we decided that the Plan does not have to pay for the dental services (D0120, D01110) received January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular peripheral nerve stimulation (electro-acupuncture device) (64555, L8679).

You asked the Plan to pre-approve the nerve stimulator. You say that the enrollee is likely to obtain significant therapeutic benefit from the neurostimulator treatment. The enrollee has tried and failed conservative care and medication therapies. The Plan denied your request. The Plan says this item is not covered and acupuncture for auricular stimulation does not meet the definition of 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve auricular peripheral nerve stimulation (electro-acupuncture device) (64555, L8679).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services represented by codes 14301 and 19301 provided on October 21, 2020.

You asked the Plan to pay for codes 14301 and 19301. You say that the medical records support the billing of codes 14301 and 19301. The Plan denied your request. The Plan says the medical records do not support the billing of codes 14301 and 19301.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 14301 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 19301 is Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).

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 codes 14301 and 19301. Our reviewer says that the medical records do not support the billing of codes 14301 and 19301. Our physician reviewer found the documentation submitted was reviewed, and, does not meet criteria. Code 14301 is not documented in the operative report. Report documents a complex closure, there is a more specific code for this procedure. Modifier 22 increased procedural services appended to code 19301 cannot be confirmed as performed. To bill this modifier, documentation should be clear on what procedures are being performed that require increased services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 14301 and 19301 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services represented by codes 14301 and 19301 provided on October 21, 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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve glucose monitoring supplies (A9276).
You asked the Plan to pre-approve glucose monitoring supplies. You say that this is necessary for the enrollee's insulin pump. The Plan denied your request. The Plan says this is not covered.
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitor (CGM) devices that do not meet the definition of a therapeutic CGM will be denied as non-covered. Code A9276 describe the supplies used with a non-therapeutic CGM.
We looked at the file and Medicare rules. The requested supplies are for use with a non-therapeutic CGM, which is non-covered. The supplies are therefore also non-covered. Therefore, we decided that the Plan does not have to pre-approve glucose monitoring supplies (A9276).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 pre-approve a Vertiflex Superion device. 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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria have not been met.

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 pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 24, 2020.
You asked the Plan to pay for the physical therapy services. You say that The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on December 17, 2020.
You asked the Plan to pay for the MRI 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. The rules say for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. However, there are two exceptions to this general rule - these are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code -- regardless of where the face-to-face service occurs -- is that of the appropriate inpatient POS code We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. The POS billed in this case is incorrect, as it reflects an outpatient hospital POS. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tint photochromatic lenses (V2744) provided on
February 26, 2021.

You asked the Plan to pay for the tint photochromatic lenses. You say that you live in a town that is in the high desert of California and has 289 sunny days out of the year. You say you need tinted lenses for your driving to various places. The Plan denied your request. The Plan says there is no coverage for tint photochromatic lenses under the Plan's vision benefit or under Medicare regulations.

Medicare generally does not cover routine eye wear services. Medicare rules say that tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as non-covered.

We looked at the file, the Plan's rules and the Medicare rules. The Plan covers eyeglass frames and eyeglass lenses including single, bifocal, trifocal, and lenticular lenses. Medicare says that tinted lenses and photochromatic lenses are not covered. Based on this information, we decided that the Plan's rules for coverage of the tint photochromatic lens have not been met. Therefore, we decided that the Plan does not have to pay for tint photochromatic lenses provided on February 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 11, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 11, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on January 12, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 12, 2021.