Persius/hicric huggingface dataset:
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an
IRF level of 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of an upper extremity (73221).
You asked the Plan to pre-approve an MRI of an upper extremity. 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 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 an MRI of an upper extremity. Our reviewer says that the services are not medically necessary. Our physician reviewer found review of the records showed no red flags such as weakness, positive Hawkins test etc. to mandate immediate MRI without a trial of physical therapy (PT). The notes state the enrollee has failed a home exercise program but no details as to duration, type etc. There is mention of a consult to PT, but none is present in the records. The medical necessity of the requested MRI of the left shoulder has not been established without first attempting monitored PT.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of an upper extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of an upper extremity (73221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330) for tooth # 3.
You asked the Plan to pre-approve the dental service. You say that you broke your tooth. You say that you
received a temporary cap to protect it. You say that your dentist advised that a problem may arise if you do not
have a root canal performed. You also say that it is painful for you to eat. The Plan denied your request. The
Plan says root canal is not listed as a covered service.
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 a
root canal (D3330) for tooth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture, cast metal framework with resin
denture bases, (D5214).
You asked the Plan to pre-approve the dental item. You say that the enrollee's insurance has requested that her
previous dentist refund the payment for the denture that was provided. You say that the previous dentist has not
refunded the full amount. You also say that the enrollee needs the lower denture so that she can eat. The Plan
denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the
frequency limit has been reached.
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 and partial lower denture is listed as
covered, the frequency limit has been reached. The record shows that the Plan paid for a lower partial denture
that was provided on February 26, 2020. Therefore, we decided that the Plan does not have to pre-approve a
partial lower denture, cast metal framework with resin denture bases, (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238).
You asked the Plan to pre-approve transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238). You say that the requested transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238) are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238).
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 transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238). Our reviewer says that the enrollee does not meet criteria for transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238). Our physician reviewer found the enrollee has varicose veins and venous insufficiency. The enrollee had undergone an ablation but still has evidence of reflux. No obstruction is noted to the arterial or venous system. The enrollee does not have an indication noted as covered in the local coverage determination. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238) have not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter placement of an intravascular stent, open or percutaneous (37239), transluminal balloon angioplasty (37248) and transcatheter placement of an intravascular stent, open or percutaneous (37238).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
April 12, 2021 to April 13, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based on Medicare guidelines, the service you and/or your provider are requesting do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is an 80-year-old male who presented to the hospital with shortness of breath. He was diagnosed with acute renal failure and given diuretics. It was determined that the diagnosis was contrast-induced nephropathy and associated acute respiratory failure. The provided records did not describe a significant enough indication for inpatient services around this elective surgery. Observation care appeared most appropriate as the enrollee was hemodynamically stable, without hypoxia at the time of admission and they were responding to initial treatment. No complex needs or lingering issues warranted inpatient services. There was insufficient evidence to suggest this enrollee would require hospitalization that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 12, 2021 to April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The provided records do not describe a significant enough indication for inpatient services around this elective surgery. Preoperative evaluation does not reveal high risk status. There is no expectation that there would likely be a complex surgery or prolonged recovery. There is no evidence to suggest this patient would require hospitalization that would likely cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested services. You say that coverage cannot be denied. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results.
Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cheat sheets (K0108) for a manual wheelchair.
You asked the Plan to pre-approve cheat sheets. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve cheat sheets (K0108) for a manual wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radio-frequency ablation for the enrollee.
You asked the Plan to pre-approve radio-frequency ablation. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not cover investigational or experimental services. 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 radio-frequency ablation. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found this procedure is considered experimental or investigational and is the subject of on-going clinical trials. This treatment is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radio-frequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radio-frequency ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental item. You say that you cannot be without teeth for 3 years. You also say that if you had not had your teeth removed, it could have poisoned your system. The Plan denied your request. The Plan says 1 partial upper denture is covered every 5 plan years. The Plan also says that the frequency limit has been reached.
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 and the requested partial upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on July 18, 2018.
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable wipes and gloves (E1399).
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy or by Medicare.
The Plan covers all items that Medicare covers. Medicare rules say that non-reusable disposable supplies are not covered. While disposable wipes and gloves may be appropriate for you 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 disposable wipes and gloves (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support that the requested services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is only covered for certain indications. We looked at the file and Medicare rules. Review of the file shows that medical records were not provided to the Plan. This means there is no documentation to support that the requested services are medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided from June 18, 2020, to June 25, 2020.
You asked the Plan to pay for home infusion therapy. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed with a valid code.
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 S9502 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) provided from June 18, 2020, to June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic scope of the knee 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 degree of arthritis on the enrollee's x-ray is too advanced to support the requested service.
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 enrollee being treated for left knee pain, medial compartment arthritis. He cites bilateral knee pain. It started gradually and has been present for six years. Exam reveals bilateral genu varum. Mild medial joint line tenderness with range of motion of 5-120 (active) is noted. X-rays of the bilateral knees show complete collapse of the medial compartment in both knees. Long leg x-rays show weight bearing line outside of the medial compartment. Stress view shows right knee preserved lateral compartment, left knee is more questionable with possible mild narrowing. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. He is noted to have had injections (with cortisone injection being 20 years ago.) However, there is no indication of a failure of medications and/or physical therapy (including for the knee osteoarthritis). Furthermore, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for 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 diagnostic scope of the knee for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, four radiographic images (D0274), prophylaxis, adult (D1110) and periodic oral evaluation (D0120) provided February 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the bitewing x-rays, dental cleaning and dental exam. You say that you were under the understanding that your plan would cover all dental procedures and it's not right that the services are not being covered. The Plan denied your request. The Plan says the services were provided OON and therefore are not covered under your 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. The Plan covers the bitewing x-rays, dental cleaning and oral exam when rendered by a network provider. 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 bitewing x-rays, dental cleaning and oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the bitewings, four radiographic images (D0274), prophylaxis, adult (D1110) and periodic oral evaluation (D0120) provided February 1, 2021 by an out-of-network (OON) provider.