Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve additional physical therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 additional physical therapy services. 
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 your condition. You have been authorized extensive 
therapy for this condition and are participating in a home exercise program. Additional therapy without 
evidence if you are moving in a positive direction or have remaining deficits that need skilled therapy is not 
medically necessary.  
 
At this time, without evidence of ongoing need or outcome of prior therapy you do not require the unique skills 
of a professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or under the supervision of a therapist. You have been compliant in 
an independent exercise program. The therapy provider notes joint laxity however, there are no objective 
imaging studies of the knee indicating pathology or orthopedic evaluation. It is unclear if the left leg pain and 
low back pain are related. The specialized skill, knowledge and judgment of a qualified therapist is not required 
at this time to establish, design and/or deliver a program to maintain your 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 additional physical therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional protective cover (CPT Code L5962).
You asked the Plan to pre-approve the cover. You say that you are requesting review of denial of the cover.
The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the cover have not been met. You do not work or live in an
environment in which the added protection of the additional protective covering is required. Medicare
Guidance says that the protective covering is only for persons who are in very difficult work areas in which the
usual covering wouldn't protect the leg. Therefore, we decided that the Plan does not have to pre-approve
additional protective cover (CPT Code L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient wound care received August 14, 2020, through August 28, 2020.
You asked the Plan to waive the copayment for outpatient wound care. You say that you should not be charged a surgery copay. The Plan denied your request. The Plan says the copayment 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 s $250 copayment per visit for Medicare-covered ambulatory surgical center and outpatient hospital facility visits. You have been asked to pay s $250 copayment for outpatient wound care. Outpatient wound care falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient wound care received August 14, 2020, through August 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean additional twelve (12) Logisticare miles.You asked the Plan to pre-approveadditional Logisticare miles. You say that you require additional mileage to get to medical appointments.The Plan denied your request. The Plan says the service is a covered benefit but your request exceeds mileage limit.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. We looked at your request, the records in the case file, and the rules. The service is a covered benefit but your request exceeds mileage limit. The health plan contract says each one-way trip must not exceed fifty (50) miles of driving distance.Therefore, we decided that the Plan does not have to pre-approvean additional twelve (12) Logisticare miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.

You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be received in another setting, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.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 the enrollee does not require the 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 (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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have waive the deductible foran office visit (99204) on September 17, 2020.You asked the Plan waive the deductible foran office visit. You say that the provider did not inform you that they were out-of-network.The Plan denied your request. The Plan says the deductible charge was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductiblechargefor your covered medical services.The Plan has followed Medicare rules by clearly disclosing in the contract thatthere is a $250deductible charge for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time an office visit was provided on September 17, 2020. Therefore, we decided that the Plan does not have waive the deductible foran office visit (99204) on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes
(D9222) and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223 x3).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of the
cover. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your handbook as a covered benefit;
therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve deep
sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent
15 minute increment (D9223 x3).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without
contrast material (CPT Code 72148) and MRI, spinal canal and contents, thoracic; without contrast material
(72146).
You asked the Plan to pre-approve the MRI's. You say that the services are necessary. The Plan denied your
request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI's. Our physician reviewer
found the records do not outline a complete neurologic exam, differential diagnosis, or recent plain film
imaging. Without the support of the documentation, medical necessity cannot be determined.
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 MRI's have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148) and MRI,
spinal canal and contents, thoracic; without contrast material (72146).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the clinical documentation provided supports the need for care in an LTACH.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the care needed can be provided in the current inpatient hospital.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 reasonableand necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveseven additional skilled nursing (SN) visits.You asked the Plan to pre-approvethe services. You say that the skilled nursing visits are medically necessary.The Plan denied your request. The Plan says two additional home health visits are approved for the NOMNC to be issued as the home health company has not done that yet. The Plan states the remaining sevenhome health SN visits are upheld as the wound no longer requires the skills of a licensed nurse.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 based on the medical records provided there is no documentation 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 forthe seven denied visits. Records report four wounds (two on the back, one on the abdomen and one on the right arm). Wound care includes cleaning with normal saline and covering with gauze. No complications or progression of the wounds is described that would justify the need for the seven additional skilled nursing visits.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-approveseven additional skilled nursing (SN) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, for example: PT/OT at the skilled nursing facility.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 rulesto 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 based on themedical records provided, 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 do not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate in this case.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 havenot been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT Code
64633).
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. You have not had the required 6
months of minimum 50% improvement in pain as your last injection was September 2020. This does not meet
the Medicare criteria for facet joint injections. The rules say repeat thermal facet joint RF ablation at the same
anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 50%
improvement in pain for at least 6 months. Therefore, we decided that the Plan does not have to pre-approve
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT);
cervical or thoracic, single facet joint (CPT Code 64633).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit provided on September 16, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe office visit. You say that please review the medical records for appeal.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 forthe outpatient office visit provided on September 16, 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 surgical placement of an endosteal implant (D6010) 
provided on September 21, 2020. 
 
You asked the Plan to pay for the dental service. You say that you did not have this service done for cosmetic 
reasons. You say that the only options you had were extensive surgery or an extraction. You say that you 
needed the implant to be able to chew food. You also say that you were not aware that the implant would not be 
covered. The Plan denied your request. The Plan says implants are not listed as a covered service. The Plan 
also says that services that are not listed, 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. The Evidence of Coverage clearly states that if a benefit is not listed in 
this chart then it is not covered and you will be responsible for 100% of the charges. Therefore, we decided that 
the Plan does not have to pay for the surgical placement of an endosteal implant (D6010) provided on 
September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure
device (CPAP).
You asked the Plan to pre-approve continued CPAP use. You say that this is medically necessary. The Plan
denied your request. The Plan says that the records show you have not met the usage requirements for
continued CPAP use.
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP four hours per night on
70% of nights during a consecutive thirty-day period anytime during the first three months of initial usage.
We looked at the file and Medicare rules. The compliance report included with the file indicates you did not
adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued CPAP
use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a
continuous positive airway pressure device (CPAP).
Please note, the Plan has approved one month of continued CPAP use to demonstrate compliance.