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

We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography (CPT code 64625 X2), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the SI joint remains experimental. More research is needed to show safety and efficacy of RFA treatment. 

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 pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography (CPT code 64625 X2), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care for the enrollee.

You asked the Plan to pre-approve home health care. You say that home health care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the current condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The wound care that is prescribed for her superficial lower extremity wounds is not complex in nature and she does not require additional skilled nursing 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an
IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that you 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.

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT Paramedic
only in certain circumstances. Medicare allows ALS paramedic intercept services only when the
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow
the volunteer ambulance company to bill for the transport or BLS services.

The Plan has confirmed that this provider does not have a contract with the volunteer ambulance company that
provided the transport services. Therefore, we decided that the Plan does not have to pay for the ambulance
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth rehabilitation services (Q3014).

You asked the Plan to waive the copayment for the telehealth rehabilitation services. You say that you were provided telehealth services by the facility and should not be charged the copayment. The Plan denied your request. The Plan says the copayment waiver for telehealth visits was not effective and the copayment was applied correctly in this case.

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 $30 copayment for Outpatient rehabilitation services.

You have been asked to pay a $30 copayment for the rehabilitation services. These rehabilitation services fall within the Outpatient rehabilitation services 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 the telehealth rehabilitation services (Q3014).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 27, 2020, and
September 8, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent
or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on August 27, 2020, and
September 8, 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.

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 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 do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. 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 you will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional outpatient home health SN visits, for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's sore is healing well and the nurse states that the enrollee can do the dressings (wound care) on the days the nurse does not visit. The Plan states they are not able to approve six additions visits because the enrollee does not need the knowledge, judgment, and skills of a qualified nurse to do those dressings. The Plan states they can be done by the enrollee.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The enrollee's wound is healing, does not require complex wound care, and the enrollee is competent and able to perform the wound care. The request for 6 more SN visits is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional outpatient home health SN visits, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation per quadrant (D4921) and that drugs medicaments dispensed in the office for home use (D9630) provided on October 6, 2020.

You asked the Plan to pay for these services. You say that you went in for a cleaning and the dentist performed a root canal. The Plan denied your request. The Plan says that these services 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation per quadrant (D4921) and that drugs medicaments dispensed in the office for home use (D9630) provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) provided on August 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that these were medically necessary services. The Plan denied your request. The Plan says they only cover out-of-network services in limited circumstances. The care provided was not urgent or pre-approved.

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 office visit (99204) provided on August 17, 2020 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 complete maxillary denture, endosteal implant, and bone replacement graft for ridge preservation provided on September 28, 2020.

You asked the Plan to pay for the complete maxillary denture, endosteal implant, and bone replacement graft. You say that you believe these services should be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective November 4, 2015, to November 4, 2021.

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 complete maxillary denture, endosteal implant, and bone replacement graft for ridge preservation provided on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen G4 portable oxygen concentrator

You asked the Plan to pre-approve an Inogen G4 portable oxygen concentrator. You say that you need this portable oxygen concentrator because you cannot carry more weight. The Plan denied your request. The Plan says that they provided you a portable oxygen concentrator on February 12, 2021.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a portable oxygen concentrator. A portable oxygen concentrator serves the same purpose as an Inogen G4 portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve an Inogen G4 portable oxygen concentrator
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000), impression casting (S0395), and physical therapy services (97750), provided on August 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

The records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. 

Medicare rules also state that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. 

Procedure code S0395 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.

Medicare rules also state that providers/suppliers must continue to report one of the appropriate therapy modifiers for any therapy code on the list of applicable therapy codes. In this case, CPT code 97750 was not billed with an appropriate modifier.

Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000), impression casting (S0395), and physical therapy services (97750), provided on August 25, 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.

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 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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for confusion and a urinary tract infection. Your medical problems 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. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says the service was already rendered and there is no claim on file.

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 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 the additional requested therapy is not generally accepted as specific
and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee
has had prior speech therapy, and the records do not demonstrate that the enrollee's cognitive/functional level
needs the additional 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 for physical therapy, by or under the
supervision of a therapist. The enrollee and caregivers have been instructed on a functional maintenance
program. The requested services are not part of a maintenance program.

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 visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional speech therapy visits for the enrollee.