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

We decided that the Plan does not have to pay for the open treatment of a Patellar fracture (27524) and removal of a support implant (20680) provided on September 28, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not payable as the provider type does not qualify for payment as an assistant at surgery.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the open treatment of a Patellar fracture (27524) and removal of a support implant (20680) provided on September 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional seven (7) PT visits.
You asked the Plan to pre-approve the additional seven (7) PT visits. The Plan denied your request. The Plan says additional PT visit are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the additional seven (7) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records the enrollee appears to have improved with therapy to the point of having "minimal limitation in ROM, strength, pain and/or function." Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 additional seven (7) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional seven (7) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxis, and two resin-based composites provided on November 11, 2020, and December 3, 2020.

You asked the Plan to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxis, and resin-based composites. You say that you were not advised that Medicare was not accepted by this provider. The Plan denied your request. The Plan says these services were rendered by a provider that has opted out of Medicare. The Plan also says that you did not contact the plan prior to receiving the services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxis, and two resin-based composites provided on November 11, 2020, and December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spondylolysis. The Intracept procedure remains experimental for back pain, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493).
You asked the Plan to pre-approve facet joint injections. You say that you are in pain and need help. The Plan
denied your request. The Plan says the submitted records do not show that the criteria for coverage have been
met.
The Plan must follow Medicare rules. Medicare rules say that Facet Joint Interventions are considered
medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of
the LCD criteria.
We looked at the file and Medicare rules. The submitted documentation does not show that the criteria for
coverage have been met. The medical records do not show that you have failed to respond to conservative
treatment, instead indicating that chiropractic care and medication help. The records also do not show a pain assessment was performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment. The request also indicates that the procedure will be performed at three levels, which exceeds the amount allowed per session per spine region. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on October 18, 2018 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
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 the additional routine transportation trips. The Plan denied your
request. The Plan says the 97th routine transportation trip and beyond is not a covered benefit.
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. The Plan covers cover 96 one-way trips per calendar year.
We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers 96
one-way trips per calendar year. The 97th routine transportation trip and beyond is not a covered benefit.
Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation
trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) and therapeutic parenteral drugs (D9610).
You asked the Plan to pre-approve the placement of an intra-socket biological dressing and therapeutic parenteral drug. You say that you are having hard time eating and, at times, in great pain. You say that you would like these services to be approved so that your dentist can do them all at once. The Plan denied your request. The Plan says placement of an intra-socket biological dressing is not listed as a covered service. The Plan also says therapeutic parenteral drug is not listed as a covered service either.
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 placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) and therapeutic parenteral drugs (D9610).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab (J9312).
You asked the Plan to pre-approve Rituximab. You say that this drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not have an FDA indication or compendia supported indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Rituximab. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 88-year-old man with a diagnosis of Constitutional (pure) red blood cell aplasia. Rituximab is not FDA-approved for the enrollee's condition. In addition, while the medical literature contains limited case reports and a letter to the editor, the use of Rituximab in this setting is not supported by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab (J9312).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) received November 16, 2020.
You asked the Plan to pay for the periodic oral evaluation. You say that the requested service was necessary. The Plan denied your request. The Plan says you have exceeded the annual allowable frequency for this 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 in excess those covered under this benefit. The Plan has submitted evidence that you exhausted the allowable annual frequency for this benefit prior to this date of service. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) received November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON bone marrow procedure. You say that you wish to be able to continue with this provider. The Plan denied your request. The Plan says there are other qualified providers who can manage your now stable condition.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 pre-approve the OON bone marrow procedure. Our reviewer says that the documentation does not show that it is medically reasonable and necessary for the requested services to be provided OON. Our physician reviewer found the record indicates that the enrollee had an autologous stem cell transplant 4.5 years ago. The record does not indicate that the enrollee is receiving active treatment. The records do not indicate that the services requested are not available in network. The elements of the coverage rules are not satisfied. 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 OON bone marrow procedure 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 pre-approve the OON bone marrow procedure. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration to be provided 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 endodontic therapy, molar tooth (D3330) received December 2, 2020.
You asked the Plan to pay for the endodontic therapy. You say that the requested service was necessary to handle excessive pain. The Plan denied your request. The Plan says the requested service is 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 endodontic therapy, molar tooth (D3330) received December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and three surgical extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the comprehensive oral evaluation and extractions. You say that your dentist advised you need to see an oral surgeon to receive these services, and you would like them to be approved for coverage. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation and three surgical extractions to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the prolonged service in an inpatient setting (99356) provided on December 9, 2020.

You asked the Plan to pay for the prolonged service. You say that you would like reconsideration because this is a separately payable service. The Plan denied your request. The Plan says that this service is considered bundled.

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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service). 

We asked our coder 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 prolonged service. Our reviewers says that CPT code 99356 meets criteria for billing and reimbursement consideration. Our reviewer found the provider clearly documented the amount of time spent with the member and other healthcare team members, as well as, detailed documentation of the services performed. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prolonged service have been met. Therefore, we decided that the Plan has to pay for the prolonged service in an inpatient setting (99356) provided on December 9, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of conscious sedation (D9239).
You asked the Plan to pre-approve the dental service. You say that the enrollee needs the sedation to make the process easier on her. You say that the enrollee has multiple sclerosis and history of a stroke. You also say that the enrollee is wheelchair bound. The Plan denied your request. The Plan says anesthesia services are not covered under the 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 an initial 15 minutes of conscious sedation (D9239).
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 believe that intensive therapy is necessary. The Plan denied your request. The Plan says you are medically stable and do not require intensive rehab services.
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 for surgical treatment of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins
when required (D2950) for tooth #18.
You asked the Plan to pre-approve the crown and core buildup. You say that you would like these services to
be approved for coverage. The Plan denied your request. The Plan says these services exceed the maximum
count allowed per period.
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, crown (D2740) and core buildup,
including any pins when required (D2950) are each limited to one procedure per tooth every five plan years.
The record shows that you received a crown (D2740) and core buildup, including any pins when required
(D2950) on tooth #18 on April 19, 2019, and your crown (D2740) and core buildup, including any pins when
required (D2950) benefits for tooth #18 have been exhausted. Therefore, we decided that the Plan does not
have to pre-approve a crown (D2740) and core buildup, including any pins when required (D2950) for tooth
#18.