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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet with minimal supervision. aily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar stabilization device implantation.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). You say that the best outcome for the enrollee would be obtained by proceeding with placement of an interlaminar stabilization device. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found in this case; the record indicates that the operative plan is repeat foraminotomy at L5-S1. The enrollee has had a decompressive laminotomy at this level previously. The elements of the coverage criteria 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 insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interlaminar stabilization device implantation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions provided from July 9, 2020, through September 3, 2020.

You asked the Plan to pay for the extractions. You say that you were at high risk due to coronavirus and the in-network dentist was not implementing protocols. You say that you went out-of-network for your own safety. The Plan denied your request. The Plan says out-of-network dental services are not covered.

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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions provided from July 9, 2020, through September 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on April 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 95885 and 95909 are not supported.
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 95885 is needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
limited (List separately in addition to code for primary procedure). The definition of code 95909 is nerve
conduction studies; 5-6 studies.
We find that CPT codes 95885 and 95909 are not supported in the medical record. Specifically, there is no
documentation of needle electromyography to support code 95885. There is no documentation of 5-6 nerve
conduction studies to support code 95909. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the
testing services rendered on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6740, D6245).
You asked the Plan to pre-approve the services. You say that you cannot chew or swallow food. The Plan
denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental services (D6740, D6245).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection of venous blood by venipuncture (G0471), the laboratory service (80053), and the travel allowance one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on May 13, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the collection of venous blood by venipuncture (G0471), the laboratory service (80053), and the travel allowance one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on May 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 6, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the member was not transported, and the definition of ambulance service has not been met.
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 March 6, 2021. 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 ambulance response and treatment, no transport provided on March 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on December 29, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 10, 2020 to September 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 19281 is not supported.
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 19281 is placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance. We find that CPT code 19281 is not supported in the medical record. Specifically, this is a device-dependent
code that was not billed with a required device code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 10, 2020 to September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture (D5225) and lower partial denture (D5226) provided February 11, 2021.

You asked the Plan to pay for the dental services. You say that you called the Plan and was told that due to your enhancement dental coverage that you had coverage that would cover the entire cost. The Plan denied your request. The Plan says these services are not listed as covered under the Plan benefits.

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 upper partial denture (D5225) and lower partial denture (D5226) provided February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that this request is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for the requested service.
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation will be covered for acute or subacute pain. 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 percutaneous vertebral augmentation. Our reviewer says that the requested procedure is not medically necessary and reasonable. Our physician reviewer found the records show that the T9 mild compression fracture may be chronic and not acute. The patient has chronic pain. No conservative measures including a brace have been tried and failed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the left knee genicular nerve block provided on September 21, 2020.

You asked the Plan to pay for injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (64454LT). You say that attempts at alleviating pain with less invasive treatment has not been successful. The Plan denied your request. The Plan says genicular nerve blocks are considered investigational and not medically necessary for the treatment of chronic knee pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (64454LT). Our reviewer says that the service was not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve block of the right knee was 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 injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (64454LT) have not been met. Therefore, we decided that the Plan does not have to pay for the left knee genicular nerve block provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary to get treatment and healing quicker. The Plan denied your request. The Plan says care can be provided safely at a less intensive setting of care, for example, at a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronavirus pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3425) provided on April 27, 2021.
You asked the Plan to pay for the apicoectomy. You say that you would like to use your medical benefits for coverage of the apicoectomy. The Plan denied your request. The Plan says an apicoectomy is not a listed benefit under your dental 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, 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 apicoectomy (D3425) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Grafix prime skin substitutes for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is only for diabetics or venous stasis wounds.
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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found this request is needed to prevent amputation. 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 been met. Therefore, we decided that the Plan has to pre-approve Grafix prime skin substitutes for the enrollee.
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 a group 2 heavy duty power wheelchair and sealed lead acid battery for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no deficits in toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the medical notes from 5/6/21 show a personal mobility deficit that impairs participation in MRADLs. However, the subsequent detailed records from physical therapy of 6/15/21 and 7/14/21 report that the enrollee is ambulating 160 feet
with a rolling walker, with no documentation of impairment in ability to participate in mobility-related activities of daily living. There is no documentation that the deficit cannot be helped by the use of a walker or manual wheelchair. 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 a group 2 heavy duty power wheelchair and sealed lead acid battery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care and insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 22867).
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your request. The Plan says the use of stabilization device has not shown in medical studies to be better than the usual fusion surgery or laminectomy for your back problem. The Plan states there is no proof or not enough proof it improves health and it was determined that there was no medical necessity for this request. The Plan states this surgery is not on the Medicare Inpatient Only List.
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 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 inpatient hospital care and insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT 22867) 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care and insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 22867).