Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided March 5, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that this claim should be paid in full. The Plan denied your request. The Plan says this service was previously covered in August 2019 and therefore was not eligible for coverage at the time of service.
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 comprehensive oral evaluation once every three years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam was previously covered on August 7, 2019. Based on this information, we determined that you were not yet eligible for coverage of another comprehensive exam at the time of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided March 5, 2021.
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 these services are medically necessary.
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not
require transfer to LTACH.

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. You are
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found
that your condition does not meet Medicare criteria for LTACH services.

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 pre-approve an astigmatism-correcting intraocular lens (A-C IOL).
You asked the Plan to pre-approve the A-C IOL. You say that you say this item would benefit you more than the standard IOL. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve an astigmatism-correcting intraocular lens (A-C IOL).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Spinal Cord Stimulator (SCS) trial.
You asked the Plan to pre-approve a SCS trial. 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 follows Medicare rules. Medicare rules say that SCS may be covered for the relief of chronic intractable pain under the specific circumstances.
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 SCS trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence-based indication for a SCS trial. The request is 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 a SCS trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a Spinal Cord Stimulator (SCS) trial.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Clarifix procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the records we received do not show notes of weather degree of turbinate hypertrophy requires surgery.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. The clarifix procedure does not address nor affect the size or shape of the inferior turbinates. The inferior turbines can be normal size but produce too much mucus, which then creates postnasal drip and drainage. The clarifix procedure is meant to address the nerve that causes the nose to produce too much mucus, but the clarifix procedure does not directly affect the anatomy of the inferior turbinate. Therefore, the clarifix procedure should not be denied because of a lack of documentation regarding the inferior turbinates. The clarifix procedure is a novel way to perform a procedure which has been performed for decades. The traditional procedure is known as a vidian nerve neurectomy. Traditionally, the patient would have to be taken to the operating room, given general anesthesia, and then the nerve would be cut through an endoscopic approach. The risks of the procedure included damage to the surrounding structures and dry eye. The clarifix procedure freezes this nerve instead of cutting it, thereby reducing the risk and potential morbidity of the procedure. This patient qualifies for the procedure based on his physical exam and diagnoses. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these services. 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 been met. Therefore, we decided that the Plan has to pre-approve the Clarifix procedure for the enrollee.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections.
You asked the Plan to pre-approve the requested services. You say that your pain is bad, and your knee locks up. The Plan denied your request. The Plan says the service is considered experimental and unproven.
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 requested services. Our physician reviewer found that a review of the literature indicates that larger studies are needed with long term follow up to determine the efficacy of this procedure. The evidence is insufficient at this time to determine that this procedure is medically necessary for your knee condition without further controlled, larger studies and long term follow up.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73560) provided on March 27, 2021.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams on this date. The Plan
denied your request. The Plan says this is not separately payable.
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 have confirmed that code 73560
has a bundled relationship with code 73562 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an x-ray (73560) provided on March 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on July 16, 2020.
You asked the Plan to pay for the non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888). The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers ambulance transportation to the nearest appropriate facility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888) have not been met. Specifically, the record shows that the enrollee received transportation services beyond the nearest appropriate facility. This means that the additional ambulance mileage is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve oncology services. You say that you would like to see this provider because you are not satisfied with the care you are receiving from the in-network providers. 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. 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 oncology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed, mattress and bed side rails.
You asked the Plan to pre-approve a semi-electric hospital bed (E0295), mattress and bed side rails. You say that you cannot get out of bed by yourself. The Plan denied your request. The Plan says the records do not indicate that you have a qualifying condition.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. The medical records do not show you require frequent changes in body position and/or has an immediate need for a change in body position. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed, mattress and bed side rails.
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. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily 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 physician reviewer found that the enrollee was admitted to the acute care hospital dehydration, urinary tract infection and acute kidney injury. His medical conditions are stable. There are no complex nursing needs. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says the continuation of SNF care is no longer medically necessary.
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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 74-year-old female with a past medical history of diabetes, hypertension, atrial fibrillation and unstable balance who presented to the acute hospital on June 17, 2021, with a fall resulting in a right hip fracture. Based on the medical records provided there is no documentation that the patient continues to require skilled nursing services or skilled therapy services. The enrollee no longer requires care on a daily basis. This patient does not require the services on an inpatient basis as services in a long-term care facility on a part time basis appear appropriate in this case. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
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 are very weak. The Plan denied your request. The Plan says your care is routine, and you do not need a team of providers.
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 physician reviewer found that you were admitted to the acute care hospital for a stroke and are now living at home. Your medical conditions are stable. There are no complex nursing needs. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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 right cervical radiofrequency ablation (RFA) of the medial branches.
You asked the Plan to pre-approve right cervical RFA of the medial branches. You say that the enrollee is having severe shoulder pain. The Plan denied your request. The Plan says the requested services are not supported by the records provided.
The Plan follows Medicare rules. Medicare rules say that RFA services are covered when 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 right cervical RFA of the medial branches. Our reviewer says that the requested injection services are not medically reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain. He had one set of right diagnostic cervical medial branch blocks (MBBs) from C4 to C7. He obtained 80% pain relief. There is no documentation of a second set of diagnostic MBBs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right cervical RFA of the medial branches have not been met. Therefore, we decided that the Plan does not have to pre-approve right cervical radiofrequency ablation (RFA) of the medial branches.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve Intracept. You say that significant clinical and diagnostic data support the medical necessity of this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this procedure is helpful for the enrollee's condition.

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 Intracept. 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 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 Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 22, 2020.
You asked the Plan to pay for services from opt out providers. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says this provider has opted out of the Medicare program and is not an eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. It has been confirmed this provider is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for physician services provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for foot infection and had left 5th toe amputation. Medical problems are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.