Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure services provided on October 15,
2020, by an OON provider.
You asked the Plan to pay for therapeutic procedure services. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not
obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 therapeutic procedure services provided on
October 15, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225).
You asked the Plan to pre-approve a flexible partial denture. You say that you do not understand the denial because dentures are covered by the Plan. It will be very expensive for you if the Plan does not cover this denture. The Plan denied your request. The Plan says this type of denture is not covered under your 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 a partial upper denture with a flexible base (D5225).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar laminectomy surgery (63047, 63099).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. 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 that the enrollee was being treated for lumbar spinal stenosis and radiculopathy. He cites low back pain with associated right lower extremity numbness. He localizes the pain from his gluteal region to his posterior thigh to his posterolateral calf. He reports that if he ambulates for more than a mile, his right foot will start to flop harder and he will experience severe numbness. The exam reveals intact sensation. Dorsiflexion and plantar flexion are 5/5.
However, detailed documentation is not evident regarding objective clinical findings of myotomal weakness, reflex loss or sensory deficits to support the diagnosis of radiculopathy, and imaging findings are not reported showing clear nerve root compression at both considered levels. Comprehensive recent, reasonable and less invasive treatments have not been documented over a three month period. There is no overall compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 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 a lumbar laminectomy surgery (63047, 63099).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
non-surgical management of a pelvic fracture after a fall. Medical conditions are stable. There are no complex
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires comprehensive therapy with close medical supervision. The Plan denied your request. The Plan says the enrollee's needs can be met 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 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 physician reviewer found that the enrollee was admitted to the acute care hospital for functional decline and liver mass. An evaluation demonstrated brain lesion for which craniotomy for excision was performed. His medical conditions are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation with and out of network tertiary level of care provider.
You asked the Plan to pre-approve the OON office consultation. You say that you need to see this spine specialist, as they have the expertise and technology that can provide the most options. The Plan denied your request. The Plan says the records do not demonstrate that the enrollee requires a tertiary level of care. The Plan says that the in network orthopedic surgeon they have referred the enrollee to, can sufficiently provide the care needed.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 OON office consultation. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to a non-tertiary level provider. There is nothing unique about the enrollee's condition that would make it medically necessary for him to see the requested tertiary level of care OON provider. The Plan has shown that they have in-network providers who meet the standards of care required for treatment of the enrollee's condition. 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 OON office consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve an office consultation with and out of network tertiary level of care provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automated blood pressure cuff.
You asked the Plan to pre-approve an automated blood pressure cuff. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says an automated blood pressure cuff is not covered by Medicare or the Plan for your condition.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automated blood pressure cuff.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device provided October 14, 2020.
You asked the Plan to pay for intermittent limb compression device. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the member's medical condition.
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 file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Specifically, the submitted medical records do not corroborate the claim that the enrollee has the required medical conditions eligible for coverage. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device provided October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 was admitted for weakness and a urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test (U0003) provided July 2, 2020.
You asked the Plan to pay for the COVID-19 test. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is covered under the hospice benefit.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the COVID-19 test (U0003) provided July 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. 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 the record shows that the enrollee was a smoker for 10 years and there is no documentation showing
that any smoking has occurred in the past 15 years.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the above-described criteria.
We reviewed the file and the Medicare rules. We find that the enrollee does not have a tobacco smoking history
of at least 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for the enrollee's shoulder surgery.
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the enrollee will not require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient services. Our physician reviewer found that the provided documentation did not reveal a medical history of expected higher than average complication risk to suggest a need for hospitalization following the approved procedure. There is no expectation that the enrollee will require hospital services that will likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for the enrollee's shoulder surgery.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nursing assessment or evaluation (T1001 x 4).
You asked the Plan to pre-approve the nursing assessment or evaluation. You say that these services are medically necessary. The Plan denied your request. The Plan says nursing assessment or evaluation is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that services with a Status Code of "I" are not covered by Medicare and cannot be paid. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nursing assessment or evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve nursing assessment or evaluation (T1001 x 4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total knee arthroplasty surgery (27447).
You asked the Plan to pre-approve this service. You say that an inpatient hospital admission is medically necessary for the enrollee. The Plan denied your request. The Plan says an inpatient hospital admission is not medically necessary for this procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that an acute inpatient hospital admission is not medically necessary. Our physician reviewer found that the enrollee has knee osteoarthritis and is requesting admission to the hospital for an elective total knee arthroplasty procedure. The provided records do not reveal sufficient support that the enrollee has a medical history or clinical situation that would require a longer than expected hospital stay or post-operative recovery. There was no expectation indicated that the enrollee would require hospital services that would likely cross two midnights. 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 an acute inpatient hospital admission for a total knee arthroplasty surgery (27447).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need continuous therapy to get back to where she was prior to her hospitalization. The Plan denied your request. The Plan says you do not require a multidisciplinary approach with specialized therapies.
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 physician reviewer found that you were admitted to the acute care hospital for lower extremity cellulitis, atrial fibrillation with rapid ventricular response and congestive heart failure. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
You asked the Plan to pre-approve a raised toilet seat. You say that the raised toilet seat is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee and elbow pads (E1399).
You asked the Plan to pre-approve the knee and elbow pads. You say that the knee and elbow pads are medically necessary. The Plan denied your request. The Plan says these are not covered items.
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 knee and elbow pads (E1399).