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

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare guidelines the enrollee does not meet the requirement for an IRF admission.
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 that the complexity of your medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID-19 pneumonia and epistaxis. Your medical problems are stable. There are no identified problems that need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower seat elevation (E2300).You asked the Plan to pre-approvethe power seat elevation. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plan says the seat elevator does not serve a primary medical purpose and is statutorily non-covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are notsick or injured.Therefore, we decided that the Plan does not have to pre-approvepower seat elevation (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PCR testing provided on February 24, 2020.Youasked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that PCR amplification techniques raise considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids,representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of patients for many of the microorganisms.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 testing have not been met.Therefore, we decided that the Plan does not have to pay forthe PCR testing provided on February 24, 2020
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you wanted to save the plan money. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 30, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay fora disposable drug delivery system (A4305) and a home infusion therapy (S9501) provided.

You asked the Plan to pay for the disposable drug delivery system and home infusion therapy. You say that you are requesting reconsideration of payment regarding this claim.The Plan denied your request. The Plan says the disposable drug delivery system does not meet the requirements for approval. The Plan also says that you request as coded for home infusion therapy is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-covered items. Medicare rules also say that procedure code S9501 is not valid for Medicare purposes and is not payable

.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the disposable drug delivery system and home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay fora disposable drug delivery system (A4305) and a home infusion therapy (S9501) provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have difficulty walking and struggle with 
your cane. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (J7325). 
 
You asked the Plan to pre-approve Synvisc injections. You say that Synvisc is medically necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says the Plan's step criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc injections. Our reviewer says 
that the enrollee does not satisfy or need an exception to the Plan's step therapy criteria. Our physician reviewer 
found there is no evidence that he has previously tried the requested Synvisc injections or is currently under 
treatment with Synvisc injections. There is no evidence that the enrollee has tried and failed the required step 
therapy drugs. There is no indication in the submitted medical records that the plan's required drug(s) are likely 
be less effective and/or likely have adverse effects for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc injections (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture, complete mandibular denture, and two removable prosthodontic procedures provided on June 26, 2019.You asked the Plan to pay forthe complete maxillary denture, complete mandibular denture, and removable prosthodontic procedures. You say that you believed the Plan would take care of the bill for your dentures in full.The Plan denied your request. The Plan says removable prosthodontic procedure is not a covered benefit. The Plan also says that your benefits for the complete maxillary denture and complete mandibular denture have been satisfied and the frequency limitations have been exceeded.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, removable prosthodontic procedure is not covered under this benefit. The contract clearly states that complete dentures are limited to one upper complete and/or one lower complete denture every five years. The record shows that you received a complete maxillary denture and complete mandibular denture on January 1, 2016, and your complete dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture, complete mandibular denture, and two removable prosthodontic procedures provided on June 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral evaluation (D0120), prophylaxis (D1110), 
2 resin based composites (D2391) and the amalgam (D2140) provided on June 3, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you have been seeing this provider 
for several years. You say that you have never had a reimbursement claim be denied from this provider. You 
also say that you have already paid for the services out of pocket and expected to be reimbursed as you always 
have. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan 
also says that payment cannot be made for services that you receive from a provider who has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the oral evaluation (D0120), prophylaxis (D1110), 2 resin based composites (D2391) and the amalgam 
(D2140) provided on June 3, 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 you disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the complexity of the enrollee's
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. He was admitted for respiratory failure and COVID-19
pneumonia. His medical problems are stable and he has no identified problems that require inpatient medical
management. He does not uire treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy
program. There is not a reasonable expectation that he 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe automatic external defibrillator (K0606) provided on June 26, 2020.You asked the Plan to pay forthe automatic external defibrillator. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the appropriate modifier has not been appended to CPT code K0606.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 code K0606 is not supported in the record. Specifically, capped rental items require an additional modifier to indicate the rental period. The submitted claim does not include one of the required modifiers. Based on this information, we decided that Medicare rules for coverage of the automatic external defibrillator have not been met.Therefore, we decided that the Plan does not have to pay forthe automatic external defibrillator (K0606) provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 5, 2020.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied
your request. The Plan says the member does not have out-of-network benefits.
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 medical services provided on May 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwelve additional outpatient physical therapy visits for the enrollee.You asked the Plan to pre-approvethe additional visits. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's current formal therapy should meet clinical expectations with the now total 24 approved visits.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 requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this conditionand it does not appear that the enrollee requires the 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 compliant in a home exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approvetwelve additional outpatient physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provideelectronic analysis of implanted neurostimulator pulse generator/transmitter(95971, 95972).You asked the Plan to provideelectronic analysis of implanted neurostimulatorpulse generator/transmitter (95971, 95972). You say that the enrollee needs this procedure and analysis.The Plan denied your request. The Plan says codes 95971 and 95972 cannot be submitted together with approved code 95970.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.A review of the National Correct Coding Initiative indicatesthat CPT codes95971, 95972cannot be submitted together with approved 95970 for Part B covered services. Based on this information, we decided that Medicare rules for coverage of electronic analysis of implanted neurostimulator pulse generator/transmitter (95971, 95972) have not been met.Therefore, we decided that the Plan does not have to provideelectronic analysis of implanted neurostimulator pulse generator/transmitter(95971, 95972).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiagnostic eye exam (92014) provided on February 28, 2020.You asked the Plan to waive the copayment fordiagnostic eye exam. You say that you believe the copay is incorrect.The Plan denied your request. The Plan says the copay was applied correctly.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 $40 copayment for vision care. You have been asked to pay a $40 copayment for diagnostic eye exam. This service falls within the vision care 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. The medical records indicate that this service was a medical eye exam not a routine eye exam.Therefore, we decided that the Plan does not have to waive the copayment fordiagnostic eye exam(92014) provided on February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion InterSpinous Spacer.
You asked the Plan to pre-approve a Superion InterSpinous Spacer. You say that the records provided support the need for the requested device. The Plan denied your request. The Plan says the service requested is considered investigational and is not the standard of care for the enrollee's back and leg pain.
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 a Superion InterSpinous Spacer. 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 chronic low back pain, degenerative disc disease, and spinal stenosis. Our physician reviewer found that interspinous process placement is considered an experimental and investigational procedure which is not included in the clinical practice guidelines and whose efficacy has not been demonstrated versus standard therapy. 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 Superion InterSpinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion InterSpinous Spacer.