Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decidedthat the Plan does not have to pay forthe surgical placement of implant body: endosteal implant provided on January 29, 2020.You asked the Plan to pay forthe endosteal implant. You say that this service should be covered because you had a different Plan previous to your current dental plan so the exclusion should not apply.The Plan denied your request. The Plan says an implant is not a covered benefit if the tooth is missing prior to the start of coverage.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 covered if the service is to replace a tooth that was missing prior to your effective date with the Plan.Therefore, we decided that the Plan does not have to pay forthe surgical placement of implant body: endosteal implant provided on January 29, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on August 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0481 is not supported.The Plan mustfollow 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 G0481 is definitive drug testing, 8-14 drug classes.We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. 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 forthe drug testing rendered on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an apicoectomy (D3425).You asked the Plan to pre-approve the apicoectomy. You say that you are unable to chew on the left side of your mouth and are in constant pain.The Plan denied your request. The Plan says this service 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 an apicoectomy (D3425).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Ultra Lightweight Manual Wheelchair with air tires (99999, K0005).
You asked the Plan to pre-approve the Ultra Lightweight Manual Wheelchair. You say that the Ultra Lightweight wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollees needs can be met by a standard wheelchair.
The Plan follows Medicare rules. Medicare rules say that Ultra Lightweight Manual Wheelchairs are covered when 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 Ultra Lightweight Manual Wheelchair. Our reviewer says that the Ultra Lightweight Manual Wheelchair is not medically necessary. Our physician reviewer found the progress notes state the patient is wheelchair bound but does not reveals an objective individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, which cannot be accommodated by a K0001 through K0004 manual wheelchair. There is no evidence of a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features that has no financial relationship with the supplier.
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 Ultra Lightweight Manual Wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an Ultra Lightweight Manual Wheelchair with air tires (99999, K0005).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost stabilization care provided on November 5, 2019 through November 12, 2019.You asked the Plan to pay forthe post stabilization care. You say that you would like reconsideration because the post stabilization care was medically necessary.The Plan denied your request. The Plan says the post stabilization care was not authorized. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 the post stabilization care. Our reviewer says that the post stabilization care services were not medically reasonable and necessary. Our physician reviewer found the treating physician did not document that the member was not stable for transfer on any date of service.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 post stabilization care have not been met.Therefore, we decided that the Plan does not have to pay forpost stabilization care provided on November 5, 2019 through November 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized, and he is ready for discharge from the acute care hospital. The enrollee needs to be transferred to a LTACH to regain maximum/prior level of functioning and continue multi-disciplinary approach to care The Plan denied your request. The Plan says transfer to a LTACH is not medically necessary at this time as the enrollee is receiving the appropriate care at the present acute care facility and still requires acute level of care services.
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 that the enrollee is currently undergoing treatment at an ACH following surgery for a perforated colon. The enrollee's post-operative course was complicated by wound dehiscence and infection. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator, with no clear evidence that ventilator liberation of decannulation are expected. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to pay for the x-rays and antiemetic drugs (73060LT, J8597, 73030LT). We decided that the Plan does not have to pay for CPT code A9270. You asked the Plan to pay for hospital services (73060LT, J8597, J3030LT, A9270). You say that the services were medically necessary. The Plan says that payment for these services are bundled. We decided that the Plan has to pay for the x-rays and antiemetic drugs (73060LT, J8597, 73030LT). The plan did not provide a copy of the claim form. No medical records were provided. Without a claim form for review, the denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the x-rays and antiemetic drugs (73060LT, J8597, 73030LT). We also decided that the Plan does not have to pay for code A9270. Code A9270 denotes items that are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for code A9270, non-covered items.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve the breast tissue reduction and the panniculectomy. We decided that the Plan does not have to pre-approve the lipectomy. You asked the Plan to pre-approve the requested procedures. You say that this is medically necessary.The Plan says that this request is not deemed medically necessary.We decided that the Planhas to pre-approve the breast tissue reduction and the panniculectomy. The Plan follows Medicare rules. Medicare rules say that mastectomy is considered reconstructive for males with Grade III or Grade IV gynecomastia. The rules also say that panniculectomy is covered when there are covered symptoms present for at least three months that are refractory to the usual standard medical therapy.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 for the panniculectomy and the breast tissue reduction. Our reviewer says that the requested procedures are medically reasonable and necessary. Our physician reviewer found that based on Medicare guidelines, gynecomastia resection should be considered reconstructive surgery and medically necessary. He has evidence of Grade III gynecomastia. With respect to lateral chest wall panniculectomy, the patient has evidence of functional impairment that has been treated with typical dermatologic management. Thus, it should be considered medically necessary as well, based on Medicare criteria.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 breast tissue reduction and the panniculectomy have been met.Therefore, we decided that the Plan has to pre-approve the breast tissue reduction and the panniculectomy. We also decided that the Plan does not have to pre-approve the lipectomy.The Plan follows Medicare rules. Medicare rules say that suction assisted lipectomy is only covered for lipoma removal.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 for the lipectomy. Our reviewer says that the requested lipectomy is not medically reasonable or necessary. Our physician reviewer found that suction-assisted lipectomy should not be considered medically necessary, as this would not be likely to address functional concerns but more of an aesthetic concern.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 lipectomy have not been met.Therefore, we decided that the Plan does not have to pre-approve the lipectomy.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 incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are not getting the proper amount of supplies. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary and mandibular dentures. You say that the dentures aremedically necessary.The Plan denied your request. The Plan says these services are not covered under your benefit plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally given your maximum level with debility, you are not expected to make significant functional progress in a predicted period of time. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. 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: 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. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 that the enrollee is currently undergoing treatment at an ACH for recurrent airway obstruction and acute renal failure. The enrollee required intubation/ventilation and was started on hemodialysis. The enrollee subsequently received a tracheotomy and appears to be tolerating ventilator weaning. It seems unlikely that decannulation would be the goal for this patient. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 95813) provided on January 16, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rulessay 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 95813 is "Electroencephalogram (EEG) extended monitoring; greater than 1 hour".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 the services. Our reviewer says that the use of CPT code 95813 is not supported by the records provided. Our physician reviewer found that the documentation does not reflect monitoring start and stop time to support CPT 95813.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 pay forthe services (CPT 95813) provided on January 16, 2019
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. Functionally given she is at contact guard assist (CGA) for mobility and does not need IRF level of therapies. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from November 29, 2019 to December 6, 2019 and from December 13, 2019 to December 15, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plandenied your request. The Plan says the enrollee's condition no longer required 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 above 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 pay for the skilled nursing services.Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from November 29, 2019 to December 6, 2019 and from December 13, 2019 to December 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesterile gloves.You asked the Plan to pre-approvesterile gloves. You say that sterile glovesare necessary.The Plan denied your request. The Plan says Medicare PartB does not usuallycover common medical supplies and sterile gloves are only covered for home dialysis.The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must primarily serve a medical purposeWe looked at the file and Medicare rules. Sterile gloves are only covered for home dialysis patients. Based on this information, we decided that Medicare rules for coverage of sterile gloves have not been met.Therefore, we decided that the Plandoes not have to pre-approvesterile gloves.