Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.

You asked the Plan to pre-approve SI joint injection. You say that the enrollee has been evaluated and treated for this pain for the past 3 years and has failed all conservative treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not had at least 3 positive tests to show if the pain is coming from the SI joint.

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 SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacroiliac (SI) joint injections are recommended as an option if the patient has failed at least 4 to 6 weeks of aggressive conservative therapy. There should be evidence of a clinical picture that is suggestive of SI injury or disease. At least 3 positive exam findings of SI joint dysfunction should be present on physical exam. The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have not been demonstrated in peer-reviewed literature. There is no documentation submitted that supports a complaint of SI joint pain. There is no documentation on physical
exam of tenderness to the SI joint and no mention of SI provocative testing being completed with positive findings. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on February 6, 2021.
You asked the Plan to pay for the ambulance service. You say that you called 911 due to waking up unable to breathe. You say that you were advised to take an Asprin. You say that you were given a breathing treatment. You also say that you refused to be transported to the hospital because you were feeling better. The Plan denied your request. The Plan says ambulance transportation is only covered when you are actually transported by ambulance. The Plan says that you were not transported by the ambulance. The Plan also says that the service is not covered.
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 February 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 the ambulance response and treatment, no transport, (A0998) provided on February 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair plastic side guards.
You asked the Plan to pre-approve the plastic side guards (K0108). You say that the enrollee needs an ultra-lightweight wheelchair, accessories and plastic side guards. The Plan denied your request. The Plan says the plastic side guards low do not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the wheelchair plastic side guards (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on July 23, 2020.

You asked the Plan to pay for these items. You say that you would like this to be paid by the Plan. The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the patient's condition.

The Plan must follow Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that these items may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant,
(D4341) for the upper right, lower right, and lower left quadrants.
You asked the Plan to pre-approve the scaling and root planing. You say that you are too old. You also say that
you do not have money to pay for these services. The Plan denied your request. The Plan says there are not 4 or
more teeth per quadrant that require scaling and root planing. The Plan also says that the requested services are
not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says that the scaling and root planing for the upper right, lower right, and lower left quadrants are not medically necessary. Our physician reviewer found the requested code D4341 requires at least 4 teeth per quadrant needing scaling and root planing. The reviewer found that the provided documentation indicates that there are 3 teeth in the upper right, 3 teeth in the lower left, and 2 teeth in the lower right require scaling and root planing. Therefore, the reviewer found that the requested code, D4341, 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 the Plan's rules for coverage of the dental services have not been met. Specifically, the requested code does not reflect the number of teeth per quadrant that require treatment. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant, (D4341) for the upper right, lower right, and lower left quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two preventive procedures (D1999 x2) provided on January 7, 2021, and January 26, 2021.
You asked the Plan to pay for the preventive procedures. You say that you should be receiving some reimbursement, and do not understand why the claims were denied. The Plan denied your request. The Plan says this service is 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, 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 two preventive procedures (D1999 x2) provided on January 7, 2021, and January 26, 2021.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 patient does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the thorax (71250).
You asked the Plan to pre-approve a CT scan of the thorax. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested service is not medically necessary.
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 thorax. Our reviewer says that the requested service is medically necessary in this case. Our physician reviewer found that the enrollee has a history of prostate cancer and high suspicion for recurrence based on a rising prostate-specific antigen level (PSA) now greater than 2 nanograms per milliliter from nadir. A CT scan is standard work-up for recurrent disease to evaluate for metastases. 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 thorax have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the thorax (71250).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from January 14, 2021, to January 17, 2021.
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you are appealing this claim. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $390 copayment for each for days 1 to 5 for Medicare-covered hospital care.
You have been asked to pay a $390 copayment for each day of the inpatient hospital admission. ($390 x 3 days = $1,170). The inpatient hospital admission falls within the "Inpatient Hospital Care" 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 the inpatient hospital admission provided from January 14, 2021, to January 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on October 8, 2020, by an
out of network (OON) provider.

You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these
services rendered by an OON provider.

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. There is no indication that these services were needed on an emergent/urgent basis. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the pathology services provided on October 8, 2020, by an out of network (OON) provider.
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 SNF services. You say that the clinical documentation provided supports the need for SNF care. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled services at an inpatient SNF 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupation therapy in the SNF. By the dates in question, the enrollee was at a supervision level with functional mobility including gait to 200 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee is living at home with weakness and trouble ambulating. He is medically stable with no complex nursing or rehabilitation needs.
He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debridement of the mastoid cavity (69222), a nasal endoscopy (31231), and a throat biopsy (42800) to be provided at an out of network facility.

You asked the Plan to pre-approve a debridement of the mastoid cavity, a nasal endoscopy, and a throat biopsy. You say that the in-network facility offered by the Plan has messed up your surgeries a couple of times and you want to do your surgery with a specific provider whom you have been seeing. The Plan denied your request. The Plan says rules for out of network care have not been met. The Plan has authorized the requested procedures with your requested provider at an in-network facility.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.

Therefore, we decided that the Plan does not have to pre-approve a debridement of the mastoid cavity (69222), a nasal endoscopy (31231), and a throat biopsy (42800) to be provided at an out of network facility.
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 service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.

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 patient does require physical and occupational therapy, but there is no
documented need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on May 15, 2020.
You asked the Plan to pay for occupational therapy. You say that many of the requested services in 2020 are not available on an outpatient basis due to the recent pandemic. You say that the patient's in-network benefits should be honored. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 occupational therapy provided on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says your records show that you can complete your daily
self-care activities with the use of your cane or walker.

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.

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to
pre-approve a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), unspecified preventive
procedure (D1999) and crown lengthening (D4249) provided on February 3, 2021 and February 4, 2021.
You asked the Plan to pay for the oral hygiene instructions (D1330), unspecified preventive procedure (D1999)
and crown lengthening (D4249). You say that bridges and crowns are covered at 50%. You say that the codes
should not have been denied and should be covered. The Plan denied your request. The Plan says the services
are not covered 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 oral
hygiene instructions (D1330), unspecified preventive procedure (D1999) and crown lengthening (D4249)
provided on February 3, 2021 and February 4, 2021.