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

We decided that the Plan does not have to pre-approve injection procedure for SI joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.

You asked the Plan to pre-approve the injection. You say that the enrollee did have a right SI joint injection in the past with only modest relief, the pain you are treating the enrollee for now is a relatively acute and new pain for them. You state the enrollee does have multiple pain generators and has found relief of their radicular systems with epidural steroid injections. You state the enrollee's new pain began more recently and is located exactly in the areas of their sacroiliac joints bilaterally and they have tenderness to palpation over both of these areas as well as positive provocative maneuvers. The Plan denied your request. The Plan says there is not a role for repeat procedures if the SI joint injection was not successful with at least 50% pain relief for multiple weeks.

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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has extensive arthritis in the lumbar spine. There was a previous right SI injection with no documentation of greater than 70% relief of symptoms. Criteria for SI injection not met. There is no evidence of the SI joint being the only pain generator for back pain. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for SI joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104 x 2),
and the porcelain pontic (D6245).

You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says bone graft at time of implant placement is not listed as a covered service. The Plan
says that porcelain pontic 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 bone
graft at time of implant placement (D6104 x 2), and the porcelain pontic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for shoulder orthosis, acromio/clavicular (canvas and webbing type) (L3670) provided February 15, 2021.

You asked the Plan to waive the copayment for the orthosis. You say that you do not want to be billed for this $24.95. You were not advised you had 3 days to return it and did not even know that this item was in your bag. You do now want the sling and is not interested in using it. The Plan denied your request. The Plan says the claim was processed, and the correct cost share was applied per the Evidence of Coverage.

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 20% coinsurance for Durable medical equipment (DME) and related supplies. 

You have been asked to pay $25 ($124.75 x 20%) for the orthosis. The orthosis falls within the Durable medical equipment (DME) and related supplies benefit category. 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 copayment for shoulder orthosis, acromio/clavicular (canvas and webbing type) (L3670) provided February 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix 10mg tablets.

You asked the Plan to pre-approve Trintellix. You say that Trintellix is medically necessary. The Plan denied
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trintellix 10mg tablets.

Benefits for Trintellix may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 22870), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. The enrollee was admitted for rectal bleeding and found to have rectal mass requiring resection. The enrollee is progressing following surgery. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bulkamid injections around urethra for the enrollee.

You asked the Plan to pre-approve the injections. You say that the enrollee has previously done pelvic floor muscle training at home and has strong pelvic floor muscles. You state the enrollee has tried and failed multiple pessaries since January 13, 2020. You state the next step recommended would be the periurethral bulking injections, which can give the enrollee significant improvement in symptoms. The Plan denied your request. The Plan says no documentation found within provided medical records that the enrollee's mixed urinary incontinence is due to intrinsic sphincter deficiency (ISD), which is a required diagnosis for this intervention.

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 injections. Our physician reviewer found urethral bulking agents are indicated for patients with intrinsic sphincter deficiency (ISD) and the medical records do not support this diagnosis. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Bulkamid injections around urethra for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 they are 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the folding walker provided on March 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 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. Therefore, we decided that the Plan does not have to pay for the folding walker provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram (ECG) interpretation and report only (93042) provided November 25, 2020.

You asked the Plan to pay for the ECG services. You say that the emergency physician's claim for interpretation service should be separately paid. It meets the conditions for separate payment as promulgated by CMS as well as CPT coding guidelines. The Plan denied your request. The Plan says this is an exact duplicate claim that has already been paid.

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, we find that CPT code 93042 is not supported in the medical record. Specifically, the records show that this is a duplicate of a claim for the same date, with the same provider and same service that was paid on check dated May 11, 2021. Based on this information, we decided that Medicare rules for coverage of the ECG services have not been met. Therefore, we decided that the Plan does not have to pay for electrocardiogram (ECG) interpretation and report only (93042) provided November 25, 2020.
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 services. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee is not on insulin.

The Plan must follow Medicare rules. The rules say that a continuous glucose monitor cannot be covered for patient who does not use insulin. 

The records do not indicate that the enrollee uses insulin. 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 pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair and the elevating leg rests provided
on June 15, 2020.

You asked the Plan to pay for the standard wheelchair and the elevating leg rests. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says these codes were billed without
a required modifier.

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 codes K0001 and K0195 are not supported in the medical record. Specifically, these items
were billed without a required capped rental modifier (KH, KI, or KJ) to indicate the month of rental. One of
these modifiers are required when billing these items. Based on this information, we decided that Medicare
rules for coverage of the standard wheelchair and the elevating leg rests have not been met. Therefore, we
decided that the Plan does not have to pay for the standard wheelchair and the elevating leg rests provided on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs could be met with either admission to a skilled nursing facility or with continued home health.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for low back pain and had kyphoplasty for a compression fracture. She was discharged home on June 14, 2021, and has ongoing weakness and trouble ambulating. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech therapy services provided on January 27, 2021, reported with primary diagnosis code F02.81.

You asked the Plan to pay for the speech therapy services as billed. You say that this was coded correctly and is medically necessary based on the records provided. The Plan denied your request. The Plan says the primary diagnosis code for this claim is a manifestation code, which is not allowed per billing guidelines.

The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with definitions that include "in other diseases classified elsewhere" are manifestation codes. These codes should be reported after the diagnosis code for the etiology. 

In this case, code F02.81 is defined as Dementia in other diseases classified elsewhere with behavioral disturbance. This is considered a manifestation code. The disease causing the dementia should be coded first. Therefore, we decided that the Plan does not have to pay for the speech therapy services provided on January 27, 2021, reported with primary diagnosis code F02.81.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.

You asked the Plan to pre-approve additional routine transportation trips. You say that that enrollee requires
this transportation. The Plan denied your request. The Plan says that the member's transportation benefit has
been exhausted.

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 a maximum of twenty-four (24) trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.