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

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on December 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because these services were authorized and medically necessary. The Plan denied your request. The Plan says no authorization was obtained for these services.

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 at issue in this case is not a network provider with the Plan. 

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 subsequent hospital care. Our reviewer says that no urgent or emergent services appeared to be required based on the provided notes. Our physician reviewer found the member's vitals were stable, not hypoxic and there were no signs of sepsis. 

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 subsequent hospital care have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for the subsequent hospital care. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), complete denture - mandibular (D5120), and complete denture - maxillary (D5110) provided January 19, 2021.
You asked the Plan to pay for the limited oral exam and the complete upper and lower dentures. You say that you were unaware that you are required to get your dental care from a network provider. The Plan denied your request. The Plan says the services are not covered by the Plan because they were provided out-of-network.
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 limited oral exam and complete upper and lower dentures when provided by an in-network dentist.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. 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. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam and complete upper and lower dentures have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), complete denture - mandibular (D5120), and complete denture - maxillary (D5110) provided January 19, 2021.
Your complaint about being unaware about the requirement to use a network provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided September 10, 2020.

You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code G0482 is not supported in the medical record. Specifically, the Place of Service (81, laboratory) documented on the claim form does not match the place of service detailed in the records (11, Office Setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble mettle crown (D2750)
for tooth #30.

You asked the Plan to pre-approve the crown. You say that this crown is medically necessary. The Plan denied
your request. The Plan says the obturation is not properly condensed or filled sufficiently close to the
radiographic apex. The concern is that the unobturated canal space may potentially lead to infection, abscess,
further bone loss, pain and/or swelling.

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 crown
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 crown. Our reviewer says that the
provided records do not support the medical reasonableness or necessity of the requested service. Our
physician reviewer found that the submitted x-rays show that the obturation is not sufficiently filled to the
apex. The criteria state that a tooth should be filled sufficiently close to the radiological apex to ensure that an
apical seal is achieved, unless there is a curvature or calcification of the canal that limits the ability to fill the
canal to the apex. The filling must be properly condensed or obturated. The elements of the coverage rule 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
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a porcelain fused to high noble mettle crown (D2750) for tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with two or more power options for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the requested wheelchair exceeds the enrollee's needs. The enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity or increased tone that needs to be managed by a power seating system, or evidence of being high risk for a pressure ulcer. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities supports that the patient can control any power options through their own individual switches.

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with two or more power options for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the arm joint.

You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this MRI is correct.

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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for this MRI. Our physician reviewer found the enrollee has bilateral shoulder pain, ongoing for several months. An examination revealed positive impingement arc and impingement signs. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less-invasive conservative care measures. There is no compelling rationale or extenuating circumstance noted to support the medical necessity of this request as an exception to guidelines. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the arm joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (67042) provided August 26, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the procedure billed is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 67042 is not supported in the medical record. Specifically, the procedure billed falls
within the 90-day follow-up period for another related surgical procedure billed. The procedure is not
separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services
(67042) provided August 26, 2020.
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 enrollee is ready for discharge and needs to go
somewhere she can get her functionality back. The Plan denied your request. The Plan says the denial of
authorization for IRF service is correct.

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 the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical 
conditions are stable. You do not have 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. You do 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.

Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from
an 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 an 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 acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a
lower level of care.

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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for non-surgical management of a
subdural hematoma after a mechanical fall. Your medical conditions 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. You do 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 you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis (J7322).

You asked the Plan to pre-approve Hymovis. The Plan denied your request. The Plan says this request does not meet the the Plan's Part B step therapy criteria for the requested viscosupplement device.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Hymovis. Our reviewer says that Hymovis (J7322) is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no evidence that the enrollee is allergic to or intolerant of these other forms of Hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of Hyaluronic acid injections. Our reviewer also found that there is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis (J7322).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in the setting of low back pain has not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure to treat low back pain. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on November 10, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and bitewing x-rays. You say that you were advised that this provider is in-network and believe the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot be waived.

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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on November 10, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x4).

You asked the Plan to pre-approve periodontal scaling and root planing. You say that the services at issue are
medically necessary. The Plan denied your request. The Plan says coverage criteria were not met, and therefore
the services are denied.

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 periodontal
scaling and root planing when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant rules to determine if
the Plan was correct in denying the request to pre-approve periodontal scaling and root planing. Our reviewer
says that given the policy requirements for radiographic images, criteria have not been met, and there is no
necessity for the services at issue. Our physician reviewer found the provided radiographic images are only
panoramic and as such does not meet criteria provided under the Plan.

We looked at this physician's review, the file, Medicare and the Plan's rules. Based on this information, we
decided that the Plan's rules for coverage of periodontal scaling and root planing have not been met.
Specifically, coverage criteria were not met for the services at issue. Therefore, we decided that the Plan does
not have to pre-approve periodontal scaling and root planing (D4341 x4).