Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care could be received in another setting.
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met at a lower level of care (ex. SNF/SAR).
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 admission to an inpatient rehabilitation facility (IRF).
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 IRF care 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 the enrollee is an 84-year-old female who was admitted to the acute care hospital on April 16, 2021. Based on the documentation provided, it is my opinion that the health plan's denial should be upheld. The enrollee does not requirethe 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.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to
the enrollee from April 12, 2021, forward.
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our
physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for
treatment in an acute inpatient mental health treatment beyond the date in question of April 12, 2021, forward
and could have been treated in a lesser restrictive setting as they were not showing any suicidal or homicidal
ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being
cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review,
the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of
inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to preapprove
continuation of inpatient mental health care provided to the enrollee from April 12, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210 x 2), the custom fabricated abutments (D6057 x 2), the implants (D6010 x 2), the bone replacement grafts (D7953 x 3), and the additional 15 minutes of deep sedation (D9223) provided on May 2, 2019.

You asked the Plan to pay for the dental services. You say that your dental plan covers extractions. You say that the denials that you have received have the wrong provider name on them. You also say that you should be reimbursed for all of the dental work that is covered under your PPO plan. The Plan denied your request. The Plan says extractions are covered after a 6 month waiting period. The Plan says that custom fabricated abutment, bone replacement graft, and implants are not listed as covered services. The Plan also says that since these services are not covered, the general anesthesia is not covered 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 and extractions are listed as covered services, there is a 6 month waiting period before you are eligible for coverage of extractions. Additionally, the custom fabricated abutment, bone replacement graft, implants, and deep sedation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 2), the custom fabricated abutments (D6057 x 2), the implants (D6010 x 2), the bone replacement grafts (D7953 x 3), and the additional 15 minutes of deep sedation (D9223) provided on May 2, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the insertion of a CardioMEMS device (33289, C2624).

You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental.

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 insertion of a CardioMEMS device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has complex cardiopulmonary disease with both congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) contributing to her ongoing cardiopulmonary disease issues. She is on a complex medical and diuretic regimen which is made more difficult to titrate owning to her baseline renal insufficiency which gets progressively worse with over-diuresis. She has been hospitalized many times over the past year including an episode of respiratory failure from pulmonary edema. The CardioMEMS device has both published data and FDA-approval for just these specific indications with documented improvement in heart failure symptoms, quality of life and decreasing the likelihood of repeat hospitalization for CHF which would be critical for this patient with so many recent hospital readmissions for decompensated CHF.

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 insertion of a CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the insertion of a CardioMEMS device (33289, C2624).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the evaluation and management services. You say that you would like reconsideration because this is the only hospital in your state with a team dedicated to your condition. The Plan denied your request. The Plan says there are network specialists available who can provide the specialized care you requested.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve evaluation and management services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 23, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per LCD L36358, the requested risk assessment panel is non-covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and diagnostic tests provided by an out-of-network provider from June 13, 2019, through July 16, 2019.
You asked the Plan to pay for the office visit and diagnostic tests. You say that the enrollee was hospitalized and follow up care was urgently needed. You say that the documentation shows the medical necessity and payment should be made. The Plan denied your request. The Plan says the services were not authorized, and the provider is not a network provider with the Plan.
The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information to determine if Medicare coverage criteria have been met and to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The plan may have to cover urgently needed services when the enrollee is outside of the service area but without records the provider has not shown that these services meet the criteria. Based on this information, we decided that Medicare rules for coverage of the office visit and diagnostic tests have not been met. Therefore, we decided that the Plan does not have to pay for the office visit and diagnostic tests provided by an out-of-network provider from June 13, 2019, through July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (98940).

You asked the Plan to pre-approve chiropractic services. You say that this should be covered because the requested chiropractor is in-network. The Plan denied your request. The Plan says the record does not show that you have a subluxation.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

We looked at the file and Medicare rules. The submitted medical records do not show that you have a subluxation. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (98940).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
Review of the file shows that the Plan uses Local Coverage Article (LCA) A57880 to support their denial. However, LCA A57880 is not valid for the provider's billing state of Wisconsin for the appropriate jurisdiction (Medicare Part B). Therefore, we are unable to use LCA A57880 to substantiate our decision. We find that the laboratory services are not supported in the medical record. Specifically, these services should be reported with code 81479. In addition, the appropriate DEX Z code identifier should be billed adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diabetic shoe for insert (A5500) and multiple density
insert (A5512).

You asked the Plan to pre-approve a diabetic shoe for insert and multiple density insert. You say that these
items are medically necessary. The Plan denied your request. The Plan says the shoes do not meet Medicare
criteria for coverage.

The Plan follows Medicare rules. Medicare rules say that the therapeutic shoes and inserts are covered when
the criteria listed in the Medicare rules section are met.

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 a diabetic shoe for insert and multiple
density insert. Our reviewer says that the requested items are not medically reasonable and necessary. Our
physician reviewer found you are a 66-year-old female with the diagnosis of diabetes mellitus type 2 with
diabetic polyneuropathy. The request for a diabetic shoe for insert (A5500) and multiple density insert (A5512)
is not medically necessary as there is no evidence on an objective physical exam in the submitted
documentation of a previous amputation of the other foot, or part of either foot, or a history of previous foot
ulceration of either foot, or a history of pre-ulcerative calluses of either foot, evidence of callus formation of
either foot, a foot deformity of either foot, or poor circulation in either foot.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a diabetic shoe for insert and multiple density insert have not been met.
Therefore, we decided that the Plan does not have to pre-approve a diabetic shoe for insert (A5500) and
multiple density insert (A5512).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 4, 2020.

You asked the Plan to pay forthe services. You say that this is medically necessary.The Plan denied your request. The Plan says the diagnosis code does not substantiate the service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no medical records pertaining to the labs in question were provided for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition.

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 services have not been met.Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by an out-of-network provider on October 6, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that this was ordered by your doctor. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 a $90 copayment for outpatient diagnostic tests/in-network/x-rays provided by someone other than your primary care physician. You have been asked to pay a $90 copayment for an x-ray. The correct copayment has been applied to the services that were provided. An x-ray falls within the outpatient diagnostic tests/in-network/x-rays provided by someone other than your primary care physician 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 an x-ray provided by an out-of-network provider on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this was previously
approved. The Plan denied your request. The Plan says this 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 insertion of a Vertiflex device. Our
reviewer says that the requested 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 that it is
safe and effective.

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 insertion of a Vertiflex device have not been met. Therefore, we decided
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 the enrollee is a 55-year-old male who was admitted an acute care hospital (ACH) on April 2, 2021. The patient is currently undergoing treatment at an ACH for aspiration pneumonitis. The enrollee has a chronic tracheotomy. The enrollee is not on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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.