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

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.

You asked the Plan to pre-approve CardioMEMS. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that the CardioMEMS device is helpful for treatment of the enrollee's condition.

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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the safety and efficacy of this device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy visits. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has received 28 physical therapy treatments. The documentation does not support that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have plateaued with therapy. Further therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point.

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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

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 is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. You appear to be more stable and require only short-term acute care services that can be safely received at the current facility. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815).

You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code.

We looked at the file and Medicare rules. The billed diagnosis code, C85.90, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device remains experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard procedure for spinal stenosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin graft services.

You asked the Plan to pre-approve the skin graft services. You say that the records provided support the need for the skin graft services being requested. The Plan denied your request. The Plan says the services in dispute are not medically necessary. The Plan says that the enrollee's condition could be treated with adequate compression, checking and treating wound infection, and other wound care.

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 skin graft services. Our reviewer says that skin graft services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested services. The enrollee's condition could be treated with adequate compression, checking and treating wound infection, and other wound care. Skin grafts are not covered for pressure sores.

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 skin graft services have not been met. Therefore, we decided that the Plan does not have to pre-approve skin graft services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450).

You asked the Plan to pay for the CT scan. You say that this service was medically necessary. The Plan denied your request. The Plan says this code is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 70450 is not supported in the medical record. Specifically, this CPT code shares a Column I / Column II relationship with CPT code 70496 that was also billed. A required modifier to allow payment for both was not included on the claim. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head (70450).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammogram.

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 the claim for procedure code 77066 is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 diagnostic mammogram.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar decompression. His medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient does 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.

Additionally, there is not a reasonable expectation that this patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you would like the enrollee to be transferred to a LTACH for continued acute management. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

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 the enrollee does not require services at the LTACH that are not already available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Our physician reviewer also found that transfer to a lower level of care may be considered when treatment is completed and the enrollee is more stable. 

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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member did not have any parental medication, complex wound care or nutrition given via a feeding tube. She was medically stable without any acute exacerbations of chronic medical problems. Her physical function was at or near her baseline and she could have received further services at a lower level of care instead of a SNF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power leg elevation device (E1010), flat calf pads
(K0108), an electronic connection between wheelchair controller and two or more power seating system motors
(E2311), and a skin protection and positioning wheelchair seat cushion (E2624).

You asked the Plan to pre-approve the items represented by current procedural terminology (CPT) codes
E1010, K0108, E2311, and E2624. You say that the records provided support the need for the items in dispute.
The Plan denied your request. The Plan says the upgraded electronics and power elevating leg rests are not
medically necessary. The Plan says that the special seat cushion is not medically necessary. The Plan says that
the calf pads are already included with the approved wheelchair.

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 items represented by current
procedural terminology (CPT) codes E1010, K0108, E2311, and E2624. Our reviewer says that the items in
dispute are not considered medically reasonable and necessary in this case. Our physician reviewer found the
requested leg rests (E1010) would exceed the enrollee's medical need. The documentation does not reveal cast
or bracing with 90 degrees of flexion prevented at the knee, lower leg edema, or that the enrollee has a
reclining wheelchair. Our physician reviewer found that an electronic connection between wheelchair
controller and two or more power seating system motors (E2311) would exceed the enrollee's medical needs.
The documentation does not reveal that a specialty controller has been approved or is needed. One actuator was
noted as being approved for the E1002 power tilt feature. Our physician reviewer found that calf resting pads
(requested under K0108, but more appropriately represented by E0995) would exceed the enrollee's medical
needs, as it is already included in the approved Group 3 power wheelchair. Our physician reviewer found that a
skin protection and positioning wheelchair seat cushion (E2624) is not supported because the documentation
does not show that the enrollee has postural asymmetries that would require a positioning accessory.

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 items represented by current procedural terminology (CPT) codes E1010,
K0108, E2311, and E2624. have not been met. Therefore, we decided that the Plan does not have to pre-approve
a power leg elevation device (E1010), flat calf pads (K0108), an electronic connection between
wheelchair controller and two or more power seating system motors (E2311), and a skin protection and
positioning wheelchair seat cushion (E2624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the bitewing x-rays (D0274) and the prophylaxis (D1110).

You asked the Plan to waive the out of network cost share for the dental services. You say that you were misinformed about the cost share and member responsibility when visiting an out of network dentist. You say that the Summary of Benefits and Quick Start Guide you have state there is a $0 copay for exams, cleanings, and x-rays that you receive out of network. You also say there is a $0 copay for comprehensive dental services you receive out of network. The Plan denied your request. The Plan says that the provider in this case is out of network. The Plan says that the Plan pays 100% of the allowable amount for services that you receive out of network. The Plan also says that the claims processed correctly per the Plan benefits.

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, dental services that you receive out of network may have a higher cost share amount. The Evidence of Coverage clearly states that you may still be billed by an out of network provider for any amount greater than the MAC payment made by the plan to the provider. This is a contractual obligation that you agreed to when you signed up for the plan. Therefore, we decided that the Plan does not have to waive the out of network cost share for the bitewing x-rays (D0274) and the prophylaxis (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an assisted living facility visit provided by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that you are appealing with supporting records. 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 assisted living facility visit provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) with sales tax (S9999) and an unspecified
service or procedure (99199).

You asked the Plan to pay for a wig with sales tax and an unspecified service or procedure. You say that the
requested item is a medical necessity for maintaining your self-esteem, reliving anxiety, assisting with daily
activities, and maintaining relationships. The Plan denied your request. The Plan says rules for payment have
not been met.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Finally, Medicare does not reimburse for sales tax. Therefore, we decided that the
Plan does not have to pay for a wig (A9282) with sales tax (S9999) and an unspecified service or procedure
(99199).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you have been under the care of the provider for five years. The Plan denied your request. The Plan says treatment for multiple myeloma is available with plan providers.

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 oncology services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.