Persius/hicric huggingface dataset:
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 enrollee has complex care needs that
require ongoing acute care. The Plan denied your request. The Plan says the guidelines for coverage have not
been met. The Plan says that LTACH care is not medically necessary.
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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital
where he is currently receiving care. There are no services available at the LTACH that the enrollee requires
that are not available at the health care setting being offered by the health plan. The requested LTACH services
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and
able to be furnished safely and effectively only on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there is appropriate care available in-plan.

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 OON services. Therefore, we decided that the Plan does not have to pre-approve a second opinion 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While you do require
physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) (73721) of the right knee.
You asked the Plan to pre-approve an MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says that your records do not show that you had a recent (within three months) six-week trial of doctor prescribed treatment.
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 reviewer says that this service is medically necessary. Our physician reviewer found while the patient's symptoms are worse on the left knee, they do have significant pain on the right as well. He has had a four week trial of physical therapy with no success, but importantly qualifies for an MRI based upon the history of medication therapy and the joint injection on the right. 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 been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) (73721) of the right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the orthotics hold your feet up straight for you to be able to walk so your feet do not collapse. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable foot insert (L3000). 
 
You asked the Plan to pre-approve a removable foot insert. You say that you are in a lot of pain and have tried 
physical therapy without getting better. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a removable foot insert (L3000).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Repatha.
Benefits for Repatha 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for addition, endoskeletal system, below knee, alignable system (L5910) and addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) (L5940).
You asked the Plan to pay for the prosthetic components. You say that this appeal is to request a microprocessor C leg for the above-knee prosthetic. The Plan denied your request. The Plan says the request for a below the knee prosthetic part does not meet the Medicare criteria and is not corroborated as the enrollee does not have a below the knee amputation.
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, we find that CPT codes L5910 and K5940 are not supported in the medical record. Specifically, these parts are for a below the knee amputation. The enrollee does not have a below the knee amputation. The enrollee has an above the knee amputations. Based on this information, we decided that Medicare rules for coverage of the prosthetic components have not been met. Therefore, we decided that the Plan does not have to pay for addition, endoskeletal system, below knee, alignable system (L5910) and addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) (L5940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup procedure (D2950) for tooth #18.
You asked the Plan to pre-approve a core buildup. You say that this service is medically necessary, and your income is limited. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup procedure (D2950) for tooth #18.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided September 1,
2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says the claim is missing required
documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery. In this case, there is no documentation that is the required
proof of delivery confirming the equipment as ordered. The record shows that the Plan made several attempts
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to
pay for the neuromuscular stimulator (E0745) provided September 1, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be met at a less level of care. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for below the knee amputation because of peripheral vascular disease. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a specialist (99204) to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that on September 21, 2020, you had eye surgery. You also say that your condition has not improved, and you are still experiencing cataract like vision. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. The records provided for review do not show that the services at issue are urgent or emergent. 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 an office visit with a specialist (99204) to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve false tooth for bridge, tooth 15 (CPT code D6242) and white glass with gold cap for bridge, tooth 14 and 16 (CPT code D6752 x 2).
You asked the Plan to pre-approve the dental services. You say that without the bridge there will be a gap on the side of your mouth which is causing you to bite the side of your cheek which is causing painful holes. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve false tooth for bridge, tooth 15 (CPT code D6242) and white glass with gold cap for bridge, tooth 14 and 16 (CPT code D6752 x 2).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary for better and faster recovery. The Plan denied your request. The Plan says you can be treated at a lower 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the record shows that you do not have identifiable skilled nursing service needs. While you have skilled therapy service needs, you do not need therapy on a daily basis. 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary, given the enrollee's response and obvious improvement in activities of daily living. The Plan denied your request. The Plan says the clinical documentation does not show that the LCD criteria has been met.
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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not achieve the expected duration of relief from the prior radiofrequency
ablation procedure. There was some pain relief for three to four months, but the percentage was not specified. Therefore, the request is considered not medically reasonable or 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation treatment for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81403, 81401, 81404,
81405) provided on August 18, 2020.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported by the
records. The Plan denied your request. The Plan says this is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a hereditary cardiovascular screening, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for a hereditary cardiovascular screening (81403, 81401, 81404, 81405) provided on
August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this would be considered a convenience item.
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 Life Alert system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex Interspinous device (22867 and 22868 ).
You asked the Plan to pre-approve a Coflex Interspinous device. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is experimental.
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 a Coflex Interspinous device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Colfex device remains experimental and more research is needed to show its safety and efficacy. 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 Coflex Interspinous device have not been met. Specifically, the service is experimental as there is not enough information on its safety and efficacy. This means the service is not medically necessary and reasonable. Therefore, we decided that the Plan does not have to pre-approve a Coflex Interspinous device (22867 and 22868).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 10, 2019 to February 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billed DRG and diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 070 and diagnosis code G93.40 (unspecified encephalopathy). 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 these services. Our reviewer says that the submitted records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee presented to the hospital with increased confusion, hallucinations, and behavioral disturbances. The record indicates that the encephalopathy is secondary to the dementia diagnosis rather than a global level F dysfunction as is characteristic of encephalopathy. The record indicates that F03.91 (unspecified dementia with behavioral disturbance) was assigned. Code G is not appropriately billed in this situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from February 10, 2019 to February 12, 2019.