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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 above. 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment 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 pay for wound care (11042, 99308 and 11045) provided on February 4, 2020. 
 
 
You asked the Plan to pay for the wound care. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the place of service code billed is incorrect because the member was custodial on the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wound care have not been met. Specifically, the record indicates that the member was receiving custodial care on the billed date of service. This means that billing place of service code 31 for a Skilled Nursing Facility is inappropriate. There is a more appropriate place of service code available. Therefore, we decided that the Plan does not have to pay for wound care (11042, 99308 and 11045) provided on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) and train of four testing (95999) provided on February 21, 2018. 
 
You asked the Plan to pay for needle electromyography and train of four testing. You say that these codes should be paid. The Plan denied your request. The Plan says these codes are not supported in the records. 
 
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 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters and 95999 is unlisted neurological or neuromuscular diagnostic procedure. 
 
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 needle electromyography and train of four testing. Our reviewer says that these codes are not supported. Our physician reviewer found the submitted medical records do not document that needle electromyography of muscles in 1 extremity or non-limb muscles was performed. The use of 95999 to report train of four testing is not supported. Train of four testing is not separately billable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography and train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95870) and train of four testing (95999) provided on February 21, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on December 19, 2019.
You asked the Plan to pay for the dental services. You say that you called the supplemental dental provider and spoke with a representative who confirmed that you were eligible for the services. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because you had these services performed on February 28, 2019. Your EOC states, this plan covers: one (1) oral exam(s), 1 cleaning(s) every year. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on December 19, 2019.
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. The Plan denied your request. The Plan says the enrollee does not have any significant skilled needs warranting an LTACH setting. 
 
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 physician reviewer found the enrollee was admitted to the current acute care hospital diagnosed with surgical wound drainage and fever following exploratory laparotomy. She was not passing stool since discharge. She was diagnosed with a fistula causing the infection. She was treated with antibiotics and provided ostomy and wound care. The enrollee at this time does not require services at the proposed LTACH that are not already available at the current acute care hospital. Additional acute care is needed. Based on the clinical condition and predicted short term improvement, it does not appear that the enrollee will require at least an additional 25 days of acute care to justify LTACH transfer. Therefore, this request for LTACH services for this enrollee is not medically necessary 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 has to pre-approve the crown (D2750) for tooth #9. 
 
You asked the Plan to pre-approve the crown for tooth #9. You say that tooth #'s 8, 9, and 10 have a great amount of attrition and erosion. You also say that you recommend crowns on these teeth to restore proper esthetics and function. The Plan denied your request. The Plan says that the enrollee did not have evidence of pathologic destruction of tooth #9 warranting a crown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown for tooth #9 when the services are medically necessary and reasonable. 
 
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 crown for tooth #9. Our reviewer says that the crown for tooth #9 meets coverage criteria. Our physician reviewer found due to the severe wear and erosion, a crown restoration (D2750) to preserve tooth #9 and to restore it to adequate function meets the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for tooth #9 have been met. Therefore, we decided that the Plan has to pre-approve the crown (D2750) for tooth #9.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
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 given the enrollee's complex postoperative course, he will require close physician monitoring. The Plan denied your request. The Plan says the enrollee has no complex wound care needs or need for daily blood work. 
 
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 physician reviewer found that the enrollee was admitted to the current acute care hospital diagnosed with stroke. His hospitalization was complicated by requiring mechanical ventilation, chest tubes, PEG, and tracheostomy. The enrollee required antibiotics, amiodarone drip, and levophed drip but completed each of those recently. He, however, still requires further weaning from mechanical ventilation or at least stabilization on ventilation. The enrollee at this time does not require services at the proposed LTACH that are not already available at the current acute care hospital. Additional acute care is needed awaiting respiratory status stability. Based on the improvement thus far, it does not appear that the enrollee will require at least an additional 25 days of acute care to justify LTACH transfer.  Therefore, this request is not medically necessary for this 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: 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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 above. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia and hospital operating room services for approved dental extractions.
You asked the Plan to pre-approve the anesthesia and hospital facility services. You say that this is medically necessary and the enrollee has severe dental anxiety and wishes to have general anesthesia. The Plan denied your request. The Plan says general anesthesia and hospital services are not covered by the enrollee's plan. However, the extractions and alveoloplasty are approved.
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 anesthesia and hospital operating room services for approved dental extractions.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit from and/or participate in an IRF 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac computed tomography (CT) with calcium scoring (75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the procedure is not medically necessary. Our physician reviewer found Cardiac CT scanning does not assess the functional significance of any coronary disease or coronary calcium identified. Moreover, screening cardiac CT scanning with calcium scoring is not recommended and has not been shown to improve cardiac outcome incremental to that achievable based on treatment guided by standard clinical risk profiling and basic lipid analysis alone. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac computed tomography (CT) with calcium scoring (75571).
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 Medicare coverage criteria for IRF services are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above. 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 preapprove
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 is reported to be medically
stable with no evidence of need for supervision by the Physician or needs acute rehab nursing care. The
enrollee does not require a skilled and an intensive therapy program. IRF admission is not medically necessary
based on lack of medical complexity. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Meropenem for the enrollee.
You asked the Plan to pre-approve Meropenem. You say that Meropenem is medically necessary. The Plan
denied your request. The Plan says this drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Meropenem for the
enrollee.
Benefits for Meropenem may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 has network providers available who can provide 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 lab work provided on November 1, 2019 by an out of network (OON) provider.
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 your muscles are weak and you cannot stand by yourself. The Plan denied your request. The Plan says your needs are not complex, and you do not need a higher intensity or team approach to rehab 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 above. 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 hospital with acute fractures of L5 and S1. You underwent removal of spinal hardware and a repeat laminectomy and posterior spinal fusion. You are generally medically stable. The documentation does not support that you have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician three times per week. While you may benefit from continuing physical and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.