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

We decided that the Plan does not have to pay for the home visit, lesion removal and nail debridement provided
by an out-of-network provider on June 3, 2020.
You asked the Plan to pay for the home visit, lesion removal and nail debridement. You say that authorization
was impossible with the incorrect insurance information. You say that the patient required the medical care
received and the claim should be reprocessed for payment. The Plan denied your request. The Plan says this
provider is not a network provider with the Plan and the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit, lesion removal and nail debridement provided by an out-of-network provider on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve True Metrix blood glucose test strips.

You asked the Plan to pre-approve True Metrix blood glucose test strips. You say that the enrollee already
purchased the reader. You say that the medical records provided support the need for the requested test strips.
The Plan denied your request. The Plan says the criteria for coverage of diabetic supplies from a non-preferred
provider have not been met.

The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as
preferred and may limit the DME to only those preferred brands and manufacturers as long as the enrollee
retains access to all medically necessary items.

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 True Metrix blood glucose test strips.
Our reviewer says that the criteria for coverage of the non-preferred brand of diabetic supplies have not been
met. Our physician reviewer found the records do not demonstrate that the enrollee has failed use of the onetouch
system, which is the Plan's preferred brand. Our physician reviewer found no evidence that the Plan's
preferred brand would be insufficient for the enrollee's medical 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 True Metrix blood glucose test strips have not been met. Therefore, we decided
that the Plan does not have to pre-approve True Metrix blood glucose test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic CGM provided on January 11, 2021.

You asked the Plan to pay for the supply allowance. The Plan denied your request. The Plan says there was no packing slip or proof of delivery submitted.

The Plan must follow Medicare rules. Medicare rules say that suppliers are required to maintain proof of delivery documentation in their files. Compliance with proof of delivery may be required as a condition of payment and must be available to Medicare contractors upon request. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic CGM provided on January 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you want a longer stay to assure you get back to base line before being released to an assisted living facility. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions to be completed by an oral surgeon.

You asked the Plan to pre-approve tooth extractions. You say that these services are necessary, and you have a broken tooth. The Plan denied your request. The Plan says extractions are not covered your dental 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 tooth extractions to be completed by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the orbits.
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that an MRI of the orbits is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not have a documented visual field defect, or ophthalmoplegia due to suspected orbital pathology. The case file does not contain the results of the MRI of the brain. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the orbits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 19, 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 27530 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 27350 is closed treatment of tibial fracture, proximal (plateau); without manipulation.We find that CPT code 27350 is not supported in the medical record. Specifically, there is no documentation of closed treatment of a proximal (plateau) tibial fracture. 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 June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you would like to get more therapy to be able to
be mobile. The Plan denied your request. The Plan says that your needs are custodial in nature.

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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) and the unspecified adjunctive service (D9999) provided on February 25, 2021.
You asked the Plan to pay for the dental services. You say that the enrollee atrial fibrillation which requires an anticoagulant. You say that the enrollee has been seeing this oral surgeon for many years. You say that you feel that this provider can safely handle this extraction with the enrollee's current physical problems. You also say that the enrollee was not comfortable looking for a new dental surgeon that they do not know. The Plan denied your request. The Plan says the provider in this case is not a participating provider. The Plan also says that services are only covered when received by a participating provider.
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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) and the unspecified adjunctive service (D9999) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and punch biopsy reported on September 2, 2020, coded with J3490, 96375-59, and 11104.You asked the Plan to pay forthe nutria-pharmaceutical injections and punch biopsy. 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 Procedures should be reportedwith the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that describe the services performed.
The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. 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 11104 is Punch biopsy of skin (including simple closure, when performed); single lesion.Payment for HCPCS/CPT codes 96372 and J3490 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. The record also does not document the punch biopsy billed. Although it is mentioned in the plan section of the note, there is no documentation of the site at which the punch biopsy was performed nor of any lesion which required this service.Therefore, we decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and punch biopsy reported on September 2, 2020, coded with J3490, 96375-59, and 11104.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).You asked the Plan to pre-approvea PET CT scan from the skull base to mid-thigh. 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 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 CT scan from the skull base to mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found given the stability of prior PET/CT scans, a 10-yearhistory of no clinical change, and the lack of conventional imaging the criteria for PET/CT per CMS guidelines are not met.
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 CT scan from the skull base to mid-thigh have not been met.Therefore, we decided that the Plan does not have to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).
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 need IRF care.The Plan denied your request. The Plan says rules for IRF care have 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 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 was admitted to an acute care hospital for evaluation of a left atrial mass. She was found to have a hip fracture as well, which was treated surgically. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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. In conclusion, there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the podiatry visit provided on February 18, 2021.
You asked the Plan to waive the deductible for the podiatry visit. You say that the doctor's office was in-network, but you saw a different doctor who was not in-network. You say you had no options on which doctor you saw. 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. Your contract with the Plan says that there is a $1,000 deductible that applies towards out-of-network podiatry visits The item or service you asked the Plan to waive the deductible for falls within the benefit category Medicare-covered podiatry services at an out-of-network specialist's office.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards out-of-network podiatry visits. This cost sharing is a contractual obligation that had not been met at the time the podiatry visit was received on February 18, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the podiatry visit provided on February 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide. You say that you cannot find another agency to provide these services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not medically necessary and your personal care needs can be met with a lower level of service.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 to pre-approve home health aide. Our reviewer says that you do not meet the Medicare criteria for the requested home health aide services. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehabilitation
services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition or perform a maintenance program. You are medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You require homemaker services and do not require the medical services of a home health aide. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide 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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no advantage in moving the member from the current acute care hospital to an LTACH.
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. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010), the repair of maxillofacial soft and/or hard tissue defect (D7955), and the radiographic/surgical implant index, by report (D6190) received December 28, 2020.
You asked the Plan to pay for the dental services (D6010, D7955, D6190). You say that the requested services were necessary for your health. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 surgical placement of implant body: endosteal implant (D6010), the repair of maxillofacial soft and/or hard
tissue defect (D7955), and the radiographic/surgical implant index, by report (D6190) received December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous device.

You asked the Plan to pre-approve the Vertiflex interspinous device. The Plan denied your request. The Plan says this is not medically necessary.

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 Vertiflex interspinous device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that you are not treated with insulin. 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 pre-approve a continuous glucose monitor (CGM).