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

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting of lumbar radiculopathy and facet joint syndrome have not been demonstrated in the peer-reviewed literature. The Plan states that more research is needed to show safety and efficacy of the procedure.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental. More research is needed to show safety and efficacy of 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
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 have been waiting for someone to change your colostomy bad and no one has gone out to the hospital. The Plan denied your request. The Plan says you need to be seen by a rehab doctor at least three (3) times a week. The Plan states you do not need an intensive teal for your care, your physical therapy needs are not complex, you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.

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 surgical management (including colostomy) of an abdominal abscess. Medical problems 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85025) provided February 5, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. There was no signed physician order for the tests at issue. There was no signed progress notes or records to support that the treating physician ordered this test. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (85025) provided February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the basic support routine supplies (A0382), ground mileage (A0425), and non-emergent ambulance transportation (A0428) provided on February 10, 2021.

You asked the Plan to pay for the basic support routine supplies, ground mileage, and non-emergent ambulance transportation. You say that you were an inpatient at one facility and needed to be transferred to another facility for radiation treatment. You also say that the hospital would not allow your wife to transport you and required that you go by ambulance. The Plan denied your request. The Plan says this claim was processed correctly.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 the basic support routine supplies, ground mileage, and non-emergent ambulance transportation. Our reviewer says that the basic support routine supplies, ground mileage, and non-emergent ambulance transportation was not medically reasonable and necessary for you. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for you. Our reviewer also found that the documentation does not support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport.

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 basic support routine supplies, ground mileage, and non-emergent ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the basic support routine supplies (A0382), ground mileage (A0425), and non-emergent ambulance transportation (A0428) provided on February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that this request is medically necessary for 
your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a total hip arthroplasty is subject to the criteria listed 
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 a total hip arthroplasty. Our reviewer 
says that the requested surgery is not medically necessary and reasonable. Our physician reviewer found that 
you are an 80-year-old male who was being treated for unilateral primary osteoarthritis, left hip. You present 
with left hip pain that had sudden onset and is accompanied by decreased mobility, difficulty sleeping, limping, 
and night pain. The pain is severe and is worsening. Symptoms are aggravated by bending, climbing stairs, 
descending stairs, lifting, movement, pushing, sitting, standing and walking. The symptoms are relieved by 
medications. In this case, detailed documentation is not evident regarding advanced joint disease demonstrated 
on x-ray or computed tomography scan. In addition, detailed documentation is not evident regarding 3 months 
of conservative treatment having been trialed and failed to include physical therapy. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the enrollee does not meet the coverage criteria for the requested total hip 
arthroplasty (27130).  
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home INR monitoring and demonstration to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 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 home INR monitoring and demonstration to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial upper denture (D5820) and an interim partial lower denture (D5821).
You asked the Plan to pre-approve the interim partial dentures. You say that the services should be covered. The Plan denied your request. The Plan says interim partial dentures are not listed as covered services.
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, interim partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim partial upper denture (D5820) and an interim partial lower denture (D5821).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that the requested Gel-One is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gel-One is not approved, as step therapy criteria have not been 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85060, 85097, 88305, 88313, 88342, 88341, 88360, 88237, 88264, 88280, 88291) provided March 18, 2021.
You asked the Plan to pay for the lab services. You say that the tests were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. There was no signed order for the tests provided. The records do not show that the treating physician discussed the need for this service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (85060, 85097, 88305, 88313, 88342, 88341, 88360, 88237, 88264, 88280, 88291) provided March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81407, 81408, 81479) provided September 17, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular Risk Assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The services at issue were cardiovascular risk assessment panels. This is not a covered service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (81286, 81407, 81408, 81479) provided September 17, 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 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 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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the ambulatory continuous glucose monitoring provided on October 28, 2020.
You asked the Plan to pay for the services provided. You say that the correct code was billed. The Plan denied your request. The Plan says that the appropriate revenue code was not submitted.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and the rules. The billing rules the Plan used, for a critical access hospital, are not binding in this case. The records show the services at issue were provided in a rural health clinic. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the ambulatory continuous glucose monitoring provided on October 28, 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 pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on September 24, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that your agent and dentist office made a huge mistake by not confirming that the dental services were covered under your plan. The Plan denied your request. The Plan says these services are not covered because they were performed after your plan had ended.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that you were not enrolled in any of the optional supplemental dental plans at the time these services were rendered.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on September 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for your condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 83-year-old female with hip/pelvic fracture with partial left hip arthroplasty. While, there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement device.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Synvisc-One. Our reviewer says that without the support of the documentation, Synvisc-One is not approved, as step criteria have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. Our physician reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).