Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet joint injections (64493, 64494).
You asked the Plan to pre-approve diagnostic facet joint injections. You say that this requested treatment is medically necessary. The Plan denied your request. The Plan says the requested procedure is not within the current standard of care.
The Plan follows Medicare rules. Medicare rules say that the requested procedure is subject to all of the criteria listed 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 diagnostic facet joint injections. Our reviewer says that the requested service is not medically necessary for the enrollee's condition. Our physician
reviewer found that there is not clear documentation of conservative therapy having failed. In addition, the patient has radicular findings which should be addressed first as the LCD criteria do not permit facet blocks when there are other clear pain generators. Therefore, the request is deemed, at this time, not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diagnostic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint injections (64493, 64494).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left knee arthroscopic surgery.

You asked the Plan to pre-approve knee surgery. You say that you cannot recommend conservative measures because the enrollee is enduring significant discomfort, pain, and swelling; therefore, you are requesting surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery 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 knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for synovial cyst (Baker) of popliteal space, left knee, ruptured, medial meniscus tear of the left knee, and lateral meniscus tear of the left knee. She presented with left knee pain that is rated at 10. She is noted to have had a magnetic resonance image (MRI) that showed a torn meniscus and possible ruptured Baker's cyst. However, detailed documentation is not evidence regarding any objective findings for review to corroborate pathology. Furthermore, detailed documentation is not evident regarding failure of recent, reasonable, and comprehensive less invasive conservative care measures.

Left knee arthroscopy surgery would not be indicated without objective clinical findings and documentation of
failure of conservative 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 knee surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve left knee arthroscopic surgery.
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says THE enrollee does not appear to need IRF level of intenstive therapy, and does not require intensive daily therapy. Needed care can be safely provided in 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found [state the medical finding(s) upon
which the physician based his/her conclusion] 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from September 17, 2021, to January 27, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you showed your insurance card on the first day of services, and the provider did not verify benefits until a lot of dental work was already done. You feel that you should not be responsible for these charges. The Plan denied your request. The Plan says out-of-network dental care is not covered, and the provider you used is not part of the Plan's dental 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.
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 dental
services provided from September 17, 2021, to January 27, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) thoracic spine (72128).
You asked the Plan to pre-approve the CT scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says that the requested does not meet medically necessity. The medical records do not show that a thoracic spine MI is contraindicated or inappropriate.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee is noted to have new onset lower extremity paraparesis in the setting of an underlying diagnosis of Parkinson's Disease (s/p 2 DBS placements). In such a setting it would be standard to evaluate for a structural etiology of this new onset paraparesis (particularly in the setting of prior intracranial surgery). This study can help rule in/out different etiologies for these symptoms. In as much it can be concluded based on the information provided that this service would be reasonable and necessary. 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 CT scan have not been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) thoracic spine (72128).
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 a protective outer surface covering.
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says you will not be using your artificial leg in very harsh conditions.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file, and Medicare rules. The records do not indicate that you have special needs for protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you do not have a car or drive, so you need additional transportation trips. The Plan denied your request. The Plan says your request is for additional trips beyond what the plan allows coverage for.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The file shows that the Plan benefit allows
coverage for a maximum of 24 one-way routine transportation trips per year. Therefore, we decided that the
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided on February 1, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the diabetic testing supplies. You say that prior authorization was not obtained because you were unaware the enrollee switched plans. The Plan denied your request. The Plan says no prior authorization was obtained.
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 diabetic testing supplies provided on February
1, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee is suffering from chronic back pain. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.

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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interlaminar devices are experimental is spine surgery. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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. You say that the enrollee needs LTACH care. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hot tub/jacuzzi.
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 the services are not covered.
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 a hot tub/jacuzzi.
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 this service is medically necessary. 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 that you were admitted for lumbar spine surgery. 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. Although you do require physical and occupational therapy, 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 you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone grafting and placement of dental implants.
You asked the Plan to pre-approve the bone grafting and implants. You say that this should be covered as
medical. The Plan denied your request. The Plan says it was found that certain parts of the request can be
approved under your dental coverage. However, neither bone grafting nor implants are covered by your dental
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-approve bone
grafting and placement of dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954) provided on February 11, 2021.
You asked the Plan to pay for the dental service. You say that you were originally told you that they would pay $62.10 for the second visit and completion of the root canal. The Plan denied your request. The Plan says prefabricated post and core in addition to a crown 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 prefabricated post and core in addition to a crown is not among those covered under this benefit. The Plan confirmed that the dental office gave you a discount on the post and core contracted rate of $122.20.
The Plan also confirmed with the dental office that they advised this service is not covered and you would be responsible for the remaining balance. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the psychiatric diagnostic evaluation
provided on February 16, 2021.
You asked the Plan to waive the coinsurance for the psychiatric diagnostic evaluation. You say that this was a
telehealth appointment. The Plan denied your request. The Plan says the out-of-network coinsurance applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40%
coinsurance for out-of-network mental health services.
You have been asked to pay $71.18, which is 40% of the allowed amount for the psychiatric diagnostic
evaluation. The allowed amount is $177.95 (40% x $177.95 = $71.18). The psychiatric diagnostic evaluation
falls within the "Outpatient mental health care" benefit category. The Evidence of Coverage states only in-network
telehealth visits are covered at no cost. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the
psychiatric diagnostic evaluation provided on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on September 21, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The submitted claim shows a place of service as an independent lab. The records do not show that the specimen was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on September 21, 2020.