Persius/hicric huggingface dataset:
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 services are medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are available at the enrollee's current level of care. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260).
You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer says that the services are not medically necessary. Our physician reviewer found review of the records shows a CT of the abdomen and pelvis report in March 2021 but no report of a CT of the chest has been enclosed. If one assumes there indeed was a negative CT of the chest on March 21, 2021 there is no justification for a repeat CT of the chest in a patient with a falling prostate-specific antigen (PSA). In addition, NCCN guidelines do not support serial CT exams of the chest no matter what the stage and especially in a case like this one where a CT of the chest 3 months ago was supposedly normal, yet to be confirmed absent inclusion in the submitted records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on July 16, 2020.

You asked the Plan to pay for the occupational therapy. 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 information to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for occupational therapy provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a rituximab injection (J9312) provided on January 7, 2020.

You asked the Plan to waive the coinsurance for a rituximab injection. You say that you were told you were not responsible for these charges. The Plan denied your request. The Plan says this processed 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% coinsurance for Medicare Part B drugs that are administered by a provider.

You have been asked to pay a $438.07 coinsurance for a rituximab injection ($2,190.34 allowed amount x 20% = $438.07). 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 coinsurance for a rituximab injection (J9312) provided on January 7, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan of a limited area.
You asked the Plan to pre-approve a PET scan of a limited area. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 a PET scan of a limited area. Our reviewer says that the services are medically necessary. Our physician reviewer found the service is covered for subsequent prescription treatment strategy for breast cancer. 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 PET scan of a limited area have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan of a limited area.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or in an assisted living facility with home health care or in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peri-auricular stimulation (P-Stim) device for the enrollee.
You asked the Plan to pre-approve these services. You say that the provider is recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says that auricular neurostimulation is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that auricular PNS is not covered by Medicare as it is not considered medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a peri-auricular stimulation (P-Stim) device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary for side
effects of hysterectomy. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nitrous oxide received on March 19, 2021.
You asked the Plan to pay for the nitrous oxide. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services received are 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 the
nitrous oxide received on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve several surgical extractions (D7210).

You asked the Plan to pre-approve the extractions. You say that due to abscesses, these teeth need to be removed. You feel these services are both medically necessary and urgent. The Plan denied your request. The Plan says they previously approved 3 extractions; however, the Plan can cover a maximum of 3 surgical extractions per calendar year. The remaining extractions requested exceed what is allowed by the 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. The Plan can cover up to three surgical extractions (recognized by procedure codes D7210-D7241) every calendar year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services exceed what is covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve several surgical extractions (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve family therapy with an out-of-network provider.
You asked the Plan to pre-approve out-of-network family therapy. You say that you previously worked with this provider and the therapist was highly effective. You say that another therapist would not provide the same quality of therapy. The Plan denied your request. The Plan says in-network providers are available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve family therapy with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an occipital nerve block.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says that this is an experimental procedure.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the block. Our reviewer says that the requested block is medically reasonable and necessary. Our physician reviewer found this is the standard of care for occipital neuralgia. The request is medically reasonable and 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 block have been met. Therefore, we decided that the Plan has to pre-approve an occipital nerve block.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system (L5828, L5845, L5848, L5856).

You asked the Plan to pre-approve an endoskeletal knee-shin system. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 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 an endoskeletal knee-shin system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for endoskeletal knee-shin system (L5828, L5845, L5848, L5856). is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as the requested leg is a microprocessor (C Leg) and exceeds the patient's medical need as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. This is the initial prosthesis and there is no evidence that the patient is unable to safely and effectively ambulate with a mechanical K3 knee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an endoskeletal knee-shin system have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal knee-shin system (L5828, L5845, L5848, L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on October 20, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4).

You asked the Plan to pre-approve the scalings and planings. You say that you believe these services should be covered.The Plan denied your request. The Plan says these services exceed 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, periodontal scaling and root planing (D4341) and is limited to one procedure per quadrant every two plan years. 

The record shows that you received two periodontal scalings and root planings (D4341 x2) on August 8, 2019 and two periodontal scalings and root planings (D4341 x2) on August 22, 2019 and your periodontal scaling and root planing (D4341) benefit for all four quadrants has been exhausted.Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you husband can hardly move and is not
able to get to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.