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

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 

We looked at the file and Medicare rules. The file shows that you weigh 163 pounds. 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 pre-approve a heavy duty extra wide hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional occupational therapy visits.
You asked the Plan to pre-approve ten (10) additional occupational therapy visits. You say that the additional therapy is medically necessary. The Plan denied your request. The Plan says based on the clinical information provided to us, the enrollee does not need the continued skills of a therapist past the five visits that are approved for transition to a home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ten (10) additional occupational 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee receives assist for staff and was noted to fluctuate in function depending on dialysis days. The enrollee was recommended to use EZ stand with staff for safety with transfers. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment purchased on January 3, 2021.You asked the Plan to reimburse you for the exercise equipment. You say that this reimbursement request should be approved because we were in the middle of a COVID-19 surge and you did not want to risk exposure going to a gym.The Plan denied your request. The Plan says per the temporary COVID-19 policy, you can use your Wellness Allowance towards the purchase of exercise equipment from October 1, 2020, through December 31, 2020.The Plan contract covers a Wellness Allowance as a supplemental benefit. We looked at the file and Plan's rules. The shows that the Plan covered a temporary COVID-19 benefit under the Wellness Allowance that provided coverage for exercise equipment purchased from October 1, 2020, through December 31, 2020 only. Therefore, we decided that the Plan does not have to reimburse you for exercise equipment purchased on January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have sacroilitis. You have tried physical therapy in the past and did not find it helpful. You had a bilateral SI joint injection on June 17, 2021. The duration and degree of relief from the first bilateral SI joint injection is not clearly documented. It is not the standard of care to repeat this injection within two weeks of the first injection. The repeat SI joint injection is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve PT services 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 physical therapy (PT) services to be provided by an out of network (OON) provider.
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 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 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 documentation does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on January 11, 2021.
You asked the Plan to pay for the dental service. You say that you do not understand why you are being charged $32. You say that this is your first oral exam this year. You also say that this should be covered. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extraction (D7140) provided on February 12, 2021.
You asked the Plan to pay for the extraction. You say that You thought that you would have the same dental coverage you had in previous years, and you never received a new booklet for 2021 stating otherwise. The Plan denied your request. The Plan says extractions are not covered by your dental benefits. The record indicates that you did not contact the Plan prior to services to verify benefits and eligibility.
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 pay for the dental extraction (D7140) provided on February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you would like reconsideration because the inpatient services are medically necessary. The Plan denied your request. The Plan says the member is noted to have no significant uncontrolled chronic conditions that pre-operatively would warrant an in-patient level of care.
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 care are met in this case.
Our physician reviewer found the provided records did not show evidence of an unstable chronic condition or other suggestion that the member would require inpatient services prior to or following the surgical procedure which is typically done at a same-day surgical center. 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 the acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve a SNF admission. You say that the enrollee has baseline functioning and is showing improvement. The Plan denied your request. The Plan says the enrollee can be safely and effectively treated in a less intensive level of care.

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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's high 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. The patient does 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 this patient does 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 a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for an interbody biomechanical device provided to the enrollee on November 10, 2020.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says that add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code.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 the denied codes is:CPT 22585:Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression)CPT 22558:Total disc arthroplasty (artificial disc), anterior approachCPT 22853:Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedureWe asked our coding 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 the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our coding reviewer found the operative report included documentation of CPT 22585, CPT 22558, and CPT 22853.  Both "add-on" codes are supported by the primary code, CPT 22558.  Per CPT guidelines for +22585 (Use 22585 in conjunction with 22554, 22556, 22558). Per the CPT guidelines for +22853 (Use 22853 in conjunction with 22100-22102, 22110-22114, 22206, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633,22634,22800-22812,63001-63040-63042,63045-63047,63050-63056,63064, 63075, 63077 ,63081, 63085, 63087, 63090, 631011, 63102, 63170-63290,633-63307). The documentation also includes date of service November 10, 2020, and billed on January 20, 2021. The Medicare allowable to submit claims is 1 year from date of service.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pay for an interbody biomechanical device provided to the enrollee on November 10, 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 reimburse you for hearing aids provided on January 27, 2021.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing
aids and hearing services must be obtained from Plan providers.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided by a Plan provider.

We looked at the file and the Plan's rules. The file shows that the hearing aids were no provided by the Plan's
hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing
aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids
provided on January 27, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital physician's care provided from
November 27, 2020, through November 29, 2020.
You asked the Plan to pay for acute inpatient hospital physician's care. You say that an inpatient stay was medically necessary. The Plan denied your request. The Plan says that services rendered could have been delivered in a short stay (observation) level of care.
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 pay for acute inpatient hospital physician's care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department (ED) on November 27, 2020 with weakness, polyuria and polydipsia. Her blood glucose was 600. She was treated with IV fluids and insulin and admitted. She was seen in consultation by Endocrinology. Her condition stabilized and improved, and she was discharged home November 29, 2020 when she was considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation 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 physician's care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital physician's care provided from November 27, 2020, through November 29, 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: 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 IRF admission is medically necessary. The Plan denied your request. The Plan says based on your current medical stability and lack of medical complexity, there is no need for physician supervision three times per week for the ongoing management of any active or acute exacerbation of chronic medical conditions.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 RFA of the genicular nerves.
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the requested procedure is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is considered experimental/investigational and is the subject of ongoing clinical
trials.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve RFA of the genicular nerves.