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

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept Procedure (22899) with the Intracept Intaosseous Nerve Ablation
System, Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance
(e.g., fluoroscopy), lumbar/sacrum (C9752), Destruction of intraosseous basivertebral nerve, each additional
vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to
code for primary procedure) (C9753). You say that the enrollee needs this procedure. The Plan denied your
request. The Plan says medical studies have not proven this procedure is helpful for treatment of the enrollee's
health problem.
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 Intracept Procedure (22899) with the
Intracept Intaosseous Nerve Ablation System, Destruction of intraosseous basivertebral nerve, first two
vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), Destruction of
intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g.,
fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753). Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the intracept procedure is experimental for the treatment of low back pain. More
research is needed to show 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 Intracept Procedure (22899) with the Intracept Intaosseous Nerve Ablation
System, Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance
(e.g., fluoroscopy), lumbar/sacrum (C9752), Destruction of intraosseous basivertebral nerve, each additional
vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to
code for primary procedure) (C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine trips. You say that you need additional routine transportation
for doctor visits. The Plan denied your request. The Plan says you have exhausted your transportation benefit.
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 routine transportation of 24 one-way routine trips.
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 provide additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this wheelchair is medically necessary. The Plan denied your request. The Plan says the criteria for a group 3 wheelchair have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided November 10, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you went to the emergency room and was in very much pain and had to wait all day to be seen. You do not want to pay $90 because you were not taken care of while you were there. The Plan denied your request. The Plan says the claim was processed and the correct copayment 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 $90 copayment per visit for emergency care. You have been asked to pay $90 copayment for the emergency visit. The emergency visit falls within the Emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #21.

You asked the Plan to pre-approve the crown. You say that this patient has an existing crown with margin decay and a root canal from several years ago. No symptoms were reported since the root canal was done. A new crown is recommended to prevent decay. The Plan denied your request. The Plan says the criteria for crowns following root canal treatment has not been met. The tooth should be filled sufficiently close to the radiological apex to ensure that an apical seal is achieved. The filling must be properly condensed and obturated.

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. The Plan covers the crown when the services are medically necessary and reasonable. 

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 crown. Our reviewer says that the requested crown does not meet criteria for coverage. Our physician reviewer found this tooth has had prior endodontic treatment and a crown. The endodontic fill is short of the apex as seen on the provided x-rays. There is also a loss of the periodontal ligament space usually seen on a healthy root, and a periapical radiolucency toward the mesial aspect of the apex. The tooth appears to have signs of a current endodontic infection. The existing crown appears to have a defective margin, however the underlying endodontic problem must be attended to prior to replacing the crown. A final restoration cannot be placed on a tooth with a current endodontic infection. The request for a crown does not meet Plan criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #21.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the treatment you need was not suggested by the in-network provider. The Plan denied your request. The Plan says there are several in-network providers who can provide the services.
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 the requested services. Therefore, we decided that the Plan does not have to pre-approve urology services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from November 21, 2020, to December 20, 2020.

You asked the Plan to pay for the SNF services provided from November 21, 2020, to December 20, 2020. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says by November 21, 2020 the enrollee no longer required daily skilled care from either a nurse or a therapist. The Plan also says that continued assistance with routine daily activities could be safely provided at the custodial level of care as it had been before.

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from November 21, 2020, to December 20, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 6, 2020, through November 16, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an observation level of care was appropriate.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was in acute inpatient care for depression when she tested positive for
COVID-19. She was transferred to acute care medical facility when she developed myalgias. She has known COVID-19 co-morbidities including hypertension, prediabetes, uses CPAP for sleep apnea and as a former smoker, and a history of cancer. She was discharged back to inpatient psychiatric care. Inpatient admission was reasonable due to the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that are documented in the medical record. The elements of the coverage determination are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 6, 2020, through November 16, 2020.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided from December 22, 2020, to December 23, 2020.
You asked the Plan to waive the copay for the services provided. You say that you needed to go to the hospital to get medical attention. The Plan denied your request. The Plan says the claim processed 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 $120 copay for emergency care. You have been asked to pay a $120 copay for the services provided. The services fall within the emergency 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. Therefore, we decided that the Plan does not have to waive the copay for the emergency room services provided from December 22, 2020, to December 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from September 28, 2020, through October 31, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says there are no daily skilled nurse or therapist needs. Medicare criteria for SNF level of coverage were not met.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF during the dates of September 28, 2020, through October 31, 2020. The documentation did not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need during the dates of September 28, 2020, through October 31, 2020. The enrollee's functional level did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment.

The enrollee did not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting from September 28, 2020, through October 31, 2020.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from September 28, 2020, through October 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine procedure.
You asked the Plan to pre-approve a spine procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 spine procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for the treatment of low back pain. More research is needed to show 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 a spine procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a spine procedure.
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 need IRF care. 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 that you have a past medical history of hypertension and breast cancer. You had an Emergency Room visit for dehydration and are currently living at home. You have ongoing weakness. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that you were not aware that you needed authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 an office visit provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 16 additional radiotherapy treatments.
You asked the Plan to pre-approve the additional radiotherapy treatments. You say that the additional 16
fractions are medically necessary. The Plan denied your request. The Plan says that the additional treatments
are not medically necessary.
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 radiotherapy treatments.
Our reviewer says that the requested services are considered medically reasonable and necessary in this case.
Our physician reviewer found 44 fractions in considered acceptable by NCCN guidelines. The treatment
requested is within the standards 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 the additional radiotherapy treatments have been met. Therefore, we decided
that the Plan has to pre-approve 16 additional radiotherapy treatments.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood exchange transfusion.

You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that
the enrollee does not have a diagnosis for which the services are covered. Our physician reviewer found the
enrollee has a diagnosis of sickle cell disease. This is not a diagnosis for which Medicare covers apheresis. The
services are therefore not reasonable or medically necessary for the 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a blood exchange transfusion.