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

We decided  that  the  Plan  does not  have to pre-approvecontinued  skilled  nursing  facility  (SNF) coverage  after December  10, 2020.You asked the  Plan to pre-approvecontinued  SNF coverage.  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  care in  a SNF when  the four  factors listed  above 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  continued  SNF coverage.  Our reviewer says  that  daily  skilled  services  are notnecessary.  Our physician  reviewer  found  you  were unable  to ambulate. You  required  moderate  assistance  with  wheelchair  mobility.  You  required  minimal  assistance  with  bed mobility.  You  required  a hoyer  lift  and  grab bars for shower  transfers.  The  documentation  does not support  that you  require  the  specialized  skills,  knowledge,  or judgment  of a skilled  professional  nurse  or qualified  therapist to safely  and effectively  provide  medically  necessary  and  reasonable  treatment.  The  documentation  does not 
support  that  skilled  nursing  or skilled  therapy  services  are required  on a daily  basis.  As a practical  matter,  you no longer  require  the  necessary  services  on an inpatient  basis,  at a SNF 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 continued  SNF coverage  have  not been met.Therefore,  we decided  that  the Plan does not  have to pre-approvecontinued  skilled  nursing  facility  (SNF) coverage  after  December10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) provided on August 27, 2020.
You asked the Plan to pay for limited oral evaluation.. You say that the service was medically necessary. The Plan denied your request. The Plan says you have exceeded your maximum benefit allowed for this service.
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. Specifically, you have exceeded your maximum benefit. Therefore, we decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe low osmolarcontrast material coded Q9967 provided on April 10, 2020.You asked the Plan to pay forthe low osmolar contrast material. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml.We find that CPT code Q9967 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. The interpretation report submitted do not indicate concentration of the contrast material; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the low osmolar contrast material have not been met.Therefore, we decided that the Plan does not have to pay forthe low osmolar contrast material coded Q9967 provided on April 10, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (75726) provided.


You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams on this date.The Plan denied your request. The Plan says this is included in a previously billed service.T

he Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. In this case, we have confirmed that code 75726 has a Column One/Column Two relationship with code 37244, which was previously billed by the same provider for the same date of service,and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for an x-ray (75726) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided  that the  Plan does not have to pre-approve a tertiary-level  referral  with  a general  surgeon.

You asked the Plan to pre-approve the referral.  You  say that this  is medically  necessary.The Plan denied  your request. The  Plan says tertiary  is  a special  level  of health  care for those  with  complex  care needs.

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 referral.  Our reviewer  says  that  the requested  services  are not  considered  medically  reasonable  and necessary  in  this  case. Our physician  reviewer found  the  umbilical  hernia  is  only  briefly  mentioned  in  the  assessment  but is  not detailed  in  size,  symptoms  or any  other  complicating  factor.  No prior  abdominal  surgery  is  reported or other consideration  that  would increase  the  complexity  or technical  aspects of  repair.  Your  medical  conditions  would  not increase  complexity of requested  surgery,  which  is generally  a standard  outpatient  or ambulatory  procedure  that  can be well performed  within  the community  and does not generally  require  a tertiary  care 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 the  referral  have  not  been met.Therefore,  we decided that the  Plan does not have to pre-approve a tertiary-level  referral  with  a general  surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forthe  bone replacement  graft  for  ridge  preservation,  extraction, and two endosteal  implants  provided  on June  29, 2020 by an OON provider.You asked the  Plan to pay  forthe  bone replacement  graft,  extraction,  and  endosteal  implants.  You  say that your insurance  agent  advised  that  you  could  go  to this  facility,  but  you  were not told  that  you  needed  to see a certain dentist.The  Plan  denied  your  request.  The  Plan  says these  services  were rendered  by an OON provider.  The Plan  also  says  that  no benefits  are available  for procedures  performed  by OON providers.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  OON.Therefore,  we decided  that  the Plan  does not  have to pay forthe  bone replacement  graft  for  ridge  preservation,  extraction,  and two endosteal  implants  provided  on June  29, 2020 by an OON provider.Your  complaint  about possibly  being  misled  by the  insurance  agentis not  a valid  appeal  for medical  coverage. This  part of  your  complaint  is  a grievance  that  must  be answered  by the Plan. Medicare  does not permit  us to make  a decision  about  these  types of  complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac
(SI)joint.
You asked the Plan to pre-approve the RFA. 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 pre-approve the RFA. Our reviewer says that the
requested SI joint RFA is not medically reasonable and necessary. Our physician reviewer found that the use of
radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear longterm
benefit over standard treatment for chronic sacroiliac joint pain. The provided medical records do not
document that the enrollee has satisfied the requirements for medical necessity.
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 RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)joint.
Appeal type: Imaging
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approvean eye refraction  and a computerized  corneal topography.You asked the  Plan to pre-approvethe services.  You  say that this  is  needed as a pre-operative  workup.The Plan  denied  your  request.  The  Plan  says this  is not  a covered  benefit  as part of  a screening  test.The  Plan  must  follow  Medicare  rules.  Medicare  rules  say  that  items  and  services  that  are not medically necessary  are not covered.  Eye  refraction  is  not a covered  service.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  services  are not  considered  medically  reasonable  and necessary  in  this  case. Our physician  reviewer found  diagnostic  corneal  topography  is  not medically  necessary.  Your  complaints,  examination  findings,  and diagnosis  of  cataract  did not warrant  testing  with  corneal  topography,  and in  most  cases, it  is  not the  standard of care for cataract  evaluation.  There  was no documentation  suggesting  corneal  disease  was related  to your complaints  or diagnoses.  Therewas no diagnosis  or interpretation  present  that  would  support  a medical  need for  topography.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-approvean eye refraction  and a computerized  corneal  topography.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe home health care services including physical therapy, occupational therapy and home health aide.You asked the Plan to pre-approvehome health care services. You say that the services requested are medically necessary.The Plan denied your request. The Plan says rules for home health care services have not been 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 services. Our reviewer says that the home health service is not medically necessary. Our physician reviewer found the documentation doesn't support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe home health care services including physical therapy, occupational therapy and home health aide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and intraoral -complete series of radiographic images (D0210) provided on August 24, 2020.You asked the Plan to pay forthe comprehensive oral evaluation and intraoral imaging. You say that you should not be charged for the items.The Plan denied your request. The Plan says the services exceed the frequencylimitation as stated in the benefit 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. The Plan covers the comprehensive oral evaluation and intraoral imaging when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation and intraoral imaging have not been met. Specifically, these procedures are allowed once every three years. The file indicates that you already have paid claims for the same services received earlier this year.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and intraoral -complete series of radiographic images (D0210) provided on August 24, 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 your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. 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 are living at home with home health services after being admitted for epistaxis with anemia. 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve CT scan of the chest for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says the evidence-based guidelines do not endorse CT of the chest after successful prostate treatment without specific indication.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have metastatic prostate cancer, which has been stable on ADT. There is no evidence of clinical (symptoms, exam findings) or biochemical (PSA rise) progression. As such, the requested imaging is not shown to be currently medically necessary or reasonable.

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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approve CT scan of the chest for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean eye refraction (92015) and computerized corneal topography (92025).You asked the Plan to pre-approvethe eye refraction and the computerized corneal topography. You say that you went to two different doctors who told you to see this provider, so it should be covered.The Plan denied your request. The Plan says determination of the refractive state of the eye is part of the routine eye examination. The Plan says that the computerized corneal topography is part of the preoperative work for cataract surgery and is not covered because it is performed as part of a screening test.The Plan must follow Medicare rules. Medicare rulessay that procedures performed in the course of any eye exam to determine the refractive state of the eyes are not covered. Medicare rules also say that corneal topography is not routinely indicated in the preoperative workup for cataract surgery and is not considered a covered benefit unless medical necessity is defended by a statement in the enrollee's record. We looked at the file and Medicare rules. Refraction services are non-covered. The records provided do not show that the corneal topography is being requested for a medically necessary reason, but rather that it is being requested as part of pre-operative work for cataract surgery. Based on this information, we decided that Medicare rules for coverage of the eye refraction and the computerized corneal topography have not been met.Therefore, we decided that the Plan does not have to pre-approvean eye refraction (92015) and computerized corneal topography (92025).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approvetwo additional  occupational  therapy  (OT) visits.You asked the Planto pre-approvethe additional  visits.  You  say that this  is  medically  necessary.The  Plandenied  your  request. The  Plansaysa similar  outcome  is  likely  with  less  treatment,  along  with  the  home program.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  based on the medical  records provided  there  is no documentation  that the  requested  therapy  is  generally  accepted as specific  and effective  therapy  for  your  condition.  Based on the available  records, you  appear to be functioning  at a high  level  and can continue  with  the  two additional occupational  therapy  visits  that  were approved and then  a home  exercise  program.  Further  therapy  beyond  this does not  appear to be likely  to achieve  any  significant  improvement  in  your  symptoms  or functional  status.We looked  at this  physician'sreview,  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  Plandoes not haveto pre-approvetwo additional  occupational  therapy  (OT) visits
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health care services including 6 skilled
nursing visits, 3 physical therapy visits, and 3 occupation therapy visits.
You asked the Plan to pre-approve the home health care services. You say that the enrollee needs these
additional home health services. The Plan denied your request. The Plan says the criteria for home health care
has not been 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 the home health care services. Our
reviewer says that the home health services are not medically necessary. Our physician reviewer found the
documentation doesn't support that the member requires skilled nursing services or skilled rehab services to
provide treatment that is medically necessary. The member does not require skilled nursing or rehab services to
effectively provide treatment, care, and/or services in order to improve the member's condition, perform a
maintenance program to maintain the member's condition and/or prevent deterioration. The member has been
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She
received skilled services at the time of discharge from the hospital but appears to be back at her baseline level
of functioning and health.
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 home health care services have not been met. Therefore, we decided that the
Plan does not have to pre-approve the home health care services including 6 skilled nursing visits, 3 physical
therapy visits, and 3 occupation therapy visits.