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

 
We decided that the Plan does not have to pay for outpatient services provided on August 15, 2020, through 
August 16, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that the right to recover for services provided to 
eligible beneficiaries by the IHS, Tribes or Tribal organizations is not extinguished by plan requirements such 
as network participation. The Plan denied your request. The Plan says Medicare rules for payment of these 
services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, the charges were not all billed under 
revenue code 0510 in this case. Therefore, we decided that the Plan does not have to pay for outpatient services 
provided on August 15, 2020, through August 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four gingival irrigations, maxillofacial prosthesis, nine 
applications of desensitizing resin, anterior resin-based composite of two surfaces, two anterior resin-based 
composites of three surfaces, and two posterior resin-based composites of two surfaces. 
 
You asked the Plan to pre-approve the dental services. You say that you do not have any extra money to pay 
for these services. The Plan denied your request. The Plan says gingival irrigation, maxillofacial prosthesis, and 
application of desensitizing resin are not covered benefits. The Plan also says that your resin-based composite 
benefit has been exhausted for the 2020 plan year. 
 
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, gingival irrigation, maxillofacial 
prosthesis, and application of desensitizing resin are not among those covered under this benefit. The contract 
also says that amalgam or resin-based composite fillings are limited to four procedures per calendar year. The 
record shows that you were approved to receive four resin-based composites on September 2, 2020, and your 
resin-based composite benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve four gingival irrigations, maxillofacial prosthesis, nine applications of desensitizing resin, anterior 
resin-based composite of two surfaces, two anterior resin-based composites of three surfaces, and two posterior 
resin-based composites of two surfaces.
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 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. 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 are no services at the LTACH that you require that are not already available and 
covered at the current setting. Therefore, this request for LTACH services is not justified and will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered when 
treatment has finished and you are more stable. 
 
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: 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 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. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The enrollee does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the 
enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator. 
 
You asked the Plan to pre-approve a sacral nerve stimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says no documentation has been submitted to show you are refractive to 
conventional therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that for sacral nerve stimulation to be covered, 
Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical 
corrective therapy). 
 
We looked at the file and Medicare rules. There is no documentation of behavioral, pharmacologic and/or 
surgical corrective therapy. Based on this information, we decided that Medicare rules for coverage of a sacral 
nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacral 
nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous transcatheter closure of the left atrial 
appendage (33340). 
 
You asked the Plan to pre-approve the percutaneous transcatheter closure of the left atrial appendage. You say 
that you would like reconsideration because this service is medically necessary and shared decision making has 
occurred. The Plan denied your request. The Plan says the submitted shared decision form indicates the second 
physician entered "by chart review only"; therefore, a formal shared decision making interaction was not 
performed as required. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the percutaneous transcatheter closure 
of the left atrial appendage. Our reviewer says that the member does not meet Medicare coverage criteria for 
the requested service. Our physician reviewer found the requirement of a formal shared decision making 
interaction with a non-interventional physician has not been fulfilled per the CMS NCD coverage rules 
 
 
 
 
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 percutaneous transcatheter closure of the left atrial appendage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous transcatheter closure of 
the left atrial appendage (33340).
Appeal type: Surgery
Decision: Favorable

e decided  that the  Planhasto pre-approvefour  additional  units  of ClariVein  (CPT 36474)You asked the  Planto pre-approvethe additional  units.  You say that this  is medically  necessary.The Plandenied  your  request. The  Plansaysthatthere  is  no evidence  to support  this  request.The  Plan  must  follow  Medicare  rules.  Medicare  rules  say  that  if  there  are no specific  coverage  rules  for an item or service,  then  that  item  or service  will  be covered  when  it  is 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 additional  units.  Our reviewer  says that  the  requested  services  are considered  medically  reasonable  and necessary  in  this  case. Our physician reviewer  found  the  documentation  is  sufficient  to demonstrate  medical  necessity  of  treatment.  There  is satisfactory  documentation  of the  severity  of  symptoms  and absence of  significant  peripheral  artery  disease. There  is  also  satisfactory  documentation  of significant  reflux  in  the  superficial  truncal  veins  bilaterally.  The health  plan  acknowledges  that  a reasonable  number  of ablative  procedures  would  indeed  be covered.  From the medical  record it appears there  was an initial  request  for  6 mechanical/chemical  ablation  procedures  coded as 6 (first  vein)  (6x36473)  procedures.  This  coding  implies  6 separate  procedures  performed  on 6 separate  days. It is possible  that  this  coding  request  may  have  elicited  some  confusion.  36474 is  an add-on code to be used  for additional  veins  at the  time  that  36473 is  coded. The  health  plan  has also  expressed  willingness  to cover medically  necessary  36474 items.  Basedon the  medical  records  provided  and  the documentation  of  what  codes the  health  plan  has  already  determined  to be coverable,  this  review  recommends  the following:  Recommend approval  of 1 instance  of 36473 per leg  and up to 2 instances  of  36474 per leg  provided  the procedures performed  in  each leg  as a single  session.  This  recommendation  assumes  no codes have  yet  been approved. It is not meant  to be in  addition  to approved codes.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  units  have  been met.Therefore,  we decided  that the  Planhas to pre-approvefour  additional  units  of ClariVein  (CPT 36474)If the Plandoes 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  toreview.  The Plan  has to show us  the mistake and/orsend 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 pneumatic compression device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says without the proper diagnosis of lymphedema extending onto the chest, trunk, and/or 
abdomen and four-week basic compression pump trial, you do not meet the LCD criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
 
 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is not a sufficient trial and failure of a standard pump. The documentation does not show objective 
physical exam findings of lymphedema of the chest, trunk, or abdomen on a physical exam portion of a 
progress note. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires or your endurance level can tolerate 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 thatMedicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve out of network specialist services. You say that you want the enrollee 
treated by out of network specialist services. The Plan denied your request. The Plan says the specialist services 
are available in network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
medical services to be provided by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lumbar Vertiflex Interspinous and/or interlaminar 
device. 
 
You asked the Plan to pre-approve the Lumbar Vertiflex Interspinous and/or interlaminar device. You say that 
you would like reconsideration because this device is medically necessary. The Plan denied your request. The 
Plan says this device is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Lumbar Vertiflex Interspinous 
and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this device is considered experimental and 
more research is needed to show its 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 the Lumbar Vertiflex Interspinous and/or interlaminar device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Lumbar Vertiflex Interspinous 
and/or interlaminar device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatientrehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to fatigue and pain. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional PT visits. 
 
You asked the Plan to pre-approve the ten (10) additional PT visits. The Plan denied your request. The Plan 
says an additional ten (10) PT visits are not medically necessary. The notes do not show the enrollee needs the 
ongoing skills of a physical therapist. 
 
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 ten (10) additional 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 the requested additional therapy is not generally 
accepted as specific and effective therapy for the enrollees condition. The enrollee has had prior therapy for 
this condition with persistent pain and it does not appear that the enrollee requires the ongoing unique skills of 
a professional therapist 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. The enrollee has been 
educated in an independent exercise program and ensure safety. The specialized skill, knowledge and judgment 
of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollees 
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 ten (10) additional PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit with emotional or behavioral assessment (99336, 96127) provided on May 26, 2020 by an out of network (OON) provider. You asked the Plan to pay for the established patient assisted living visit with emotional or behavioral assessment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 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 has network providers available who can provide 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. Therefore, we decided that the Plan does not have to pay for the established patient assisted living visit with emotional or behavioral assessment (99336, 96127) provided on May 26, 2020 by an out of network (OON) provider.