Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories and upgraded electronics.

You asked the Plan to pre-approve power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311). You say that the enrollee needs a Group 3 power wheelchair, accessories and upgraded electronics. The Plan denied your request. The Plan says there is not a medical need to control the power options through the joystick.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The record shows upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options. Based on this information, we decided that Medicare rules for coverage of power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), power wheelchair electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories and upgraded electronics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan of the lumbar spine (72131) performed on February 15, 2020.
You asked the Plan to pay for a CT scan of the lumbar spine. You say that the claim at issue denied as a duplicate in error. The Plan denied your request. The Plan says rules for payment have not been met because the claim at issue is a duplicate claim.
The Plan must follow Medicare rules. Medicare 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. Based on this information, we decided that Medicare rules for coverage of a CT scan of the lumbar spine have not been met. Specifically, the Plan has documented previous
processing and payment for the claim at issue. Therefore, we decided that the Plan does not have to pay for a
CT scan of the lumbar spine (72131) performed on February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on February 19, 2021.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says payment is not allowed because review of the claim information shows this service was related to a prohibited telemarketing contact.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral orthosis provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lens enhancements provided on January 22, 2021.
You asked the Plan to pay for the eyeglass lens enhancements. The Plan denied your request. The Plan says lens enhancements are not a covered vision benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan does not provide coverage for eyeglass lens enhancements. Therefore, we decided that the Plan does not have to pay for eyeglass lens enhancements provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy services.
You asked the Plan to pre-approve the endodontic therapy services. You say that you are in pain, and you need this root canal. The Plan denied your request. The Plan says the services which remain in dispute are not a covered benefit under your contract.
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 endodontic therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound prep services provided on October 19, 2020.
You asked the Plan to pay for the services provided. You say that the documentation supports the procedure codes. The Plan denied your request. The Plan says the billed code cannot be verified.
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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 square centimeters or 1% of body area of infants and children.
We find that CPT code 15002 is not supported in the medical record. If lesion removal, incision, or repair requires debridement of non-viable tissue surrounding a lesion, incision, or injury in order to complete the procedure, the debridement is not separately reportable. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the wound prep services provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Intraosseous Nerve Ablation System.
You asked the Plan to pre-approve the Intracept Intraosseous Nerve Ablation System. You say that this request is medically necessary. The Plan denied your request. The Plan says there is little evidence in medical literature to suggest that this is an appropriate procedure for back pain.
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 Intracept Intraosseous Nerve Ablation System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 70-year-old woman who has chronic low back with scoliosis. In this case, the requested procedure is still considered experimental/ investigational. It is specifically noted that the Federal Drug Administration approved the device, not the procedure.
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 Intracept Intraosseous Nerve Ablation System have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Intraosseous Nerve Ablation System.
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 it is felt that LTACH would increase the chances of a speedy recovery. The Plan denied your request. The Plan says there is no need for LTACH care over the current facility.

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 was admitted with an altered mental status and a sacral decubitus ulcer. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. Transfer to an LTACH is not medically reasonable and necessary. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300).
You asked the Plan to pre-approve a wheelchair power seat elevation system. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is a non-covered benefit.
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 a wheelchair power seat elevation system (E2300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epoetin beta injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not show a hemoglobin of less than 10/g/dL before the initiation of therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found as of the time of the initial request for the Mircera (Epoetin beta) injections on 01/02/2021 the documentation does not support that the requested drug was medically reasonable and necessary for the enrollee as her hemoglobin level was greater than 10 grams/dL. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Epoetin beta injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital 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 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 acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.

You asked the Plan to pre-approve a wheelchair ramp. The Plan denied your request. The Plan says the service is not covered by the plan.

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 a wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmological services and an ophthalmic biometry study to be provided out-of-network.
You asked the Plan to pre-approve ophthalmological services and an ophthalmic biometry study to be provided. You say that the enrollee is elsewhere due to his job. The Plan denied your request. The Plan says there is no medically necessary reason to have to go out of the service area. Effective and appropriate care can be delivered in the service area.
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 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 ophthalmological services and an ophthalmic biometry study to be provided out-of-network.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tenodesis of long tendon of biceps.
You asked the Plan to pre-approve tenodesis of long tendon of biceps (23430). You say that the enrollee needs this surgery. The Plan denied your request. The Plan says there is no documented failure of conservative management, the exam is not supportive of decreased functionality, and the magnetic resonance imaging is not supportive of a biceps tear.
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 tenodesis of long tendon of biceps (23430). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for biceps surgery is not met. There is no documentation of significant functional deficit. There is no documentation of conservative measures to include physical therapy. The magnetic resonance imaging does not show tear. Surgery not needed at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of tenodesis of long tendon of biceps (23430) have not been met. Therefore, we decided that the Plan does not have to pre-approve tenodesis of long tendon of biceps.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on April 28, 2020.
You asked the Plan to pay for the nursing facility visit. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and the claim should be processed for payment at the maximum amount allowed. The Plan denied your request. The Plan says prior authorization was required but 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 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 the nursing facility visit provided by an out-of-network provider on April 28, 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 the enrollee meets the criteria for IRF care, and you feel the enrollee will benefit from rehab in a way that cannot be accomplished at a lower level of care. 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 peripheral vascular disease and gangrene of lower extremity and had a below the knee amputation. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology visit to be provided by an out of network provider.

You asked the Plan to pre-approve a dermatology visit with and out of network provider. You say that you have seen this provider and wish to continue to see him for your routine dermatology needs. The Plan denied your request. The Plan says there are providers of this specialty in your assigned network.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a dermatology visit to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the upper extremity.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says there are no lab studies to show why the study is needed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI. Our physician reviewer found that in this case, the record indicates that the enrollee had hand swelling. He was treated with steroids and had improvement within a few days. He resumed normal activity feeling he did too much after a few days and the swelling returned. No physical therapy was attempted. The record does not indicate an adequate trial of conservative treatment. The records do not support medical necessity of the requested service. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair.

You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says the wheelchair is not reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. The requested wheelchair has added capabilities that are not needed for use in the home. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair.