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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the evaluation and one of the x-rays. We decided that the Plan does not have to pay for the two additional x-rays.
You asked the Plan to pay for the evaluation and x-rays. You say that you were directed to this provider by the Plan. The provider called to verify that they are in-network, and you saw this provider for multiple visits in 2020. You were not told at any point this provider was out-of-network. The Plan says that this provider is out-of-network, and out-of-network dental care is not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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.
We decided that the Plan has to pay for the limited evaluation and one of the x-rays.
You say that you were directed to see this provider by the Plan. You included a screenshot of the Plan's Find A Provider page with this provider's information listed. We requested additional information from the Plan to verify any provider information you were given, relevant call logs, or verification of the provider's network status. This information was not provided for review, nor was there evidence that this argument was investigated at the Plan level. With the information included in this case, it is not unreasonable to conclude that the provider is either in-network or you were given misinformation.
The dental benefit can cover up to two oral exams every year and one dental x-ray. The Plan is vague regarding which specific exams and x-rays may be covered. You were provided a limited oral exam and three dental x-rays. We have determined that the Plan should cover these services as in-network. Therefore, we decided that the Plan has to pay for the limited exam and one of the x-rays.
We also decided that the Plan does not have to pay for the two additional x-rays.
Though the Plan offers a dental benefit in excess of Medicare coverage, only one dental x-ray may be covered per year under this benefit. You received three (two intraoral images and a panoramic x-ray), so two of these exceed the benefit maximum of one per year. Therefore, we decided that the Plan does not have to pay for the two additional x-rays provided on November 24, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial upper (D5225) and lower (D5226) dentures with flexible bases, a temporary partial denture (D5821), bone replacement graft (D7953) and nitrous oxide analgesia (D9230).
You asked the Plan to pre-approve the dental services. You say that your plan covers up to $2,000 per year and that amount should cover these services. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve partial upper (D5225) and lower (D5226) dentures with flexible bases, a temporary partial denture (D5821), bone replacement graft (D7953) and nitrous oxide analgesia (D9230).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an OON provider.
You asked the Plan to pre-approve a consultation to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide these services. Therefore, coverage criteria have not been met.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a consultation to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepositron emission tomography (PET) scan of brain (78608).You asked the Plan to pre-approvePET scan of brain. You say that this is medically necessary.The Plan denied your request. The Plan says criteria for an FDG PET scan have not been met.The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when the enrollee meets diagnostic criteria for both AD and FTD.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 PET scan of brain. Our reviewer says that the requested service is not medically necessary and reasonable. Our physician reviewer found that in this case the records which were provided for review did not demonstrate that the member currently meets the diagnostic criteria for both AD and FTD as required by the NCD. Rather, the notes indicated that the etiology of the member's dementia has yet to be determined (and there are a wide spectrum of differential diagnoses). In as much at this time as the member does not meet diagnostic criteria for both AD and FTD this service would not meet the Medicare criteria for coverage We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan of brain have not been met.Therefore, we decided that the Plan does not have to pre-approvepositron emission tomography (PET) scan of brain (78608).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.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. The enrollee was admitted following a seizure and asystolic cardiac arrest. The enrollee is undergoing ventilator weaning. He continues to receive acute critical care services and they have not been denied. The record does not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran arthroscopy (29823) provided on October 22, 2020.You asked the Plan to pay foran arthroscopy. You say that this is supported in the records.The Plan denied your request. The Plan says this code is not documented.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 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 an arthroscopy. Our reviewer says that this code is not supported. Our physician reviewer found the medical records provided do not include sufficient documentation to meet definition criteria for an arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). Therefore, this service cannot be verified.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an arthroscopy have not been met.Therefore, we decided that the Plan does not have to pay foran arthroscopy (29823) provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device and appliances provided on October 28, 2020.
You asked the Plan to pay for Pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and Segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). You say that the intermittent limb compression device and appliances were medically necessary. The Plan denied your request. The Plan says documentation submitted did not sufficiently document the enrollee's medical condition to support the medial necessity for the billed supply code nor indicate the provider discussed the need for the device.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The medical record shows no edema to the extremities and does not mention a pneumatic compressor in the Plan notes. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device and appliances provided on October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95861 is not supported.
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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documentation of
needle electromyography of two extremities. 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 pay for the testing services rendered on November 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on April 10, 2020, to January 15, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that you reached your maximum out of pocket amount. You say that these charges should be paid. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection.
2020
Date of Service
Allowed Amount
Coinsurance
Amount Being Asked to Pay
April 10, 2020
$4,609.60
20%
$921.92
May 8, 2020
$4,590.40
20%
$918.08
June 5, 2020
$4,590.40
20%
$918.08
July 3, 2020
$4,590.40
20%
$317.50 (out-of-pocket maximum reached)
2021
Date of Service
Allowed Amount
Coinsurance
Amount Being Asked to Pay
January 15, 2021
$4,590.40
20%
$918.08
Total Amount Being Asked to Pay: $921.92 + $918.08 + $918.08 + $317.50 + $918.08 = $4,073.34
The correct coinsurance has been applied to the injections that were provided. An injection falls within the Medicare Part B prescription drugs 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 coinsurance for an injection provided by a participating provider on April 10, 2020, to January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation -established patient (D0120) and periodontal maintenance (D4910) provided January 25, 2021, by an out-of-network (OON) provider.You asked the Plan to pay forthe periodic dental exam and periodontal maintenance. You say that you have been seeing this provider for years and felt uncomfortable going to a different provider since you do not know their disinfecting procedures during the pandemic.The Plan denied your request. The Plan says this provider is not contracted withthe Plan and the Plan had other providers who could have rendered the same care therefore the services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodic dental exam and periodontal maintenance when the services are performed by a network provider. We looked at the file and Medicare rules. The requested provider in thiscase is not a network provider with the Plan at the time of the service. 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.Based on this information, we decided that the Plan's rules for coverage of the periodic dental exam and periodontal maintenance have not been met.Therefore, we decided that the Plan doesnot have to pay forthe periodic oral evaluation -established patient (D0120) and periodontal maintenance (D4910) provided January 25, 2021, by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve High-Intensity Focused Ultrasound (HIFU) treatment.
You asked the Plan to pre-approve High-Intensity Focused Ultrasound (HIFU) treatment. You say that the requested HIFU treatment is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested HIFU treatment. 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 High-Intensity Focused Ultrasound (HIFU) treatment. Our reviewer says that the enrollee does not meet criteria for the requested HIFU treatment. Our physician reviewer found the enrollee is diagnosed with prostate cancer. The LCD requirement is recurrent disease after radiation. Based on the documentation provided for review, the request is for HIFU before treatment. The LCD requirements have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of High-Intensity Focused Ultrasound (HIFU) treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve High-Intensity Focused Ultrasound (HIFU) treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the full length hospital bed rails (E0310).
You asked the Plan to pre-approve the full length hospital bed rails. You say that your mother was issued a half rail hospital bed following hip surgery. She is now moving a lot in bed and you are afraid she will fall out of bed and injure herself. A full rail bed would help to keep her from falling out. The Plan denied your request. The Plan says side rails used as a restraint to prevent falls or wandering is not covered as this is for safety and convenience.
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 not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the full length hospital bed rails (E0310).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted provides no additional information that justifies this request.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do 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. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does 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 in a SNF. You do 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, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on July 21, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that one would assume the providers would have coordinated the referral and the procedure. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on July 21, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 3 power wheelchair and accessories.You asked the Plan to providea Group 3 power wheelchair and accessories. You say that you need a replacement power wheelchair.The Plan denied your request. The Plan says the notes do not show that you have any of the conditions required for medical necessity.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; or3. 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 providea Group 3 power wheelchair and accessories.