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

We decided that the Plan does not have to pre-approvemanipulation of the left knee joint (including traction) under anesthesia.You asked the Plan to pre-approveknee surgery. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not undergone conservative treatment.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 todetermine if the Plan was correct in denying the request to pre-approve knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee status post left total knee arthroplasty. The enrollee complains of left knee pain, swelling, and stiffness. She is having trouble regaining flexion. Current clinical examination documented range of motion 10 to 80 degrees with no signs/symptoms of infection or instability. Records indicate that she underwent an initial post-operative physical therapy evaluation on November 4, 2020. However, there are no records indicating her response or compliance with physical therapy. Current evidence-based medical literature would not support manipulation under anesthesia at this time pending documented failure of first-line conservative treatment, such as injection, physical therapy, and exercise.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvemanipulation of the left knee joint (including traction) under anesthesia
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 26, 2020.You asked the Plan to pay for the physician's services. You say that the enrollee was seen by the physician as a follow up visit to an emergency room visit and the enrollee's PCP would not provide a referral because the enrolleewas not an active patient with the PCP. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 Plandid not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided on March 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forthis service. You say that you purchased a supplemental package which covers out of network services for chiropractic treatments at 50%. You say that before the COVID 19 shut down your chiropractic treatments in February were reimbursed.The Plan denied your request. The Plan says enrolleesmust use contract providers and the chiropractic office used is not associated with the required specialty health group. 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan states specific chiropractic providers must be used to have services covered. The provider in this case is not a network provider with the Plan. Therefore, we decided that the Plan does not have to pay forchiropractic services provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network
(OON) urologist.
You asked the Plan to pre-approve the OON urology services. You say that the medical records provided
support the need for the requested services. The Plan denied your request. The Plan says there are in-network
options available to provide the services requested.
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
the medical services to be provided by an out-of-network (OON) urologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you feel you need acute care.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 you require short-term acute care services, but it is not clearthat long-term acute care is needed. There are no services at the LTACH that you require that are not already available and covered at a short-term acute care hospital. Therefore, this request for LTACH services is not medically reasonable and 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs LTACH services.The Plan denied your request. The Plan says admission to LTACH 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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include ventilatorsupport, tracheostomy care, neurologic monitoring, surveillance laboratory studies, tubefeeding, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance response and treatment, no transport (A0998) provided on April 13, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service provided is not a covered benefit under themember's contractual policy as shewas not transported.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 13, 2020. The ambulance benefit is a transportation benefit. When there is no transportby the billing party, neither Medicare nor the Plan pays for the service provided.Therefore, we decided that the Plan does not have to pay fortheambulance response and treatment, no transport (A0998) provided on April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea raised toilet seat for the enrollee.You asked the Planto pre-approvea raised toilet seat. You say that this is not medically necessary.The Plandenied your request. The Plansaysthis item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plandoes not haveto pre-approvea raised toilet seat for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 determineif the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the current acute care hospital with abdominal pain with CT showing evidence suggestive of discitis/osteomyelitis. Neurosurgery was consulted due to atypical myoclonus and concern for anoxic injury. He was admitted to the ICU following asystole/PEA arrest. He required mechanical ventilation and breathing treatments and has endocarditis requiring IV antibiotics. Recently he was febrile and had hypotension.The enrollee appears to be unstable. Additional short term acute care services are needed and can safely be completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not available at the current facility or lower level of care. Therefore, this request for LTACH services will be considered 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe home infusion immunotherapy administrative services provided on July 27, 2020 billed with code S9338.You asked the Planto pay forthe home infusion administrative services. You say that these services should be paid due to medical necessity.The Plandenied your request. The Plansaysthis was billed with an invalid code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9338 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion administrative services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe home infusion immunotherapy administrative services provided on July 27, 2020 billed with code S9338.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules.Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe root canal (D3320) and the unspecified preventive service (D1999) provided on July 15, 2020.You asked the Plan to pay forthe dental services. You say that you have always paid your monthly premium as soon as you got the bill. You also say that in June you never received the bill so you had to call to pay your bill for June and July.The Plan denied your request. The Plan says letters were sentto you requesting payment of past due premiums to avoid termination of the Platinum Dental Rider on May 08, 2020, and June 08, 2020. The Plan says a final letter was sent to you on July 01, 2020 to inform the Platinum Dental Rider was terminated as of June 30, 2020 and reduced to the embedded Supplemental Dental Benefit. The Plan also says that the services you received on the date of service are not listed as covered in the Supplemental 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 services you received are notamong thosecovered under the Supplemental Dental Benefit. The record shows that you were not enrolled in the Platinum Dental Plan at the time you received these services.Therefore, we decided that the Plan does not 
have to pay forthe root canal (D3320) and theunspecified preventive service (D1999) provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe telehealth services coded G2025 provided on May 5, 2020.You asked the Plan to pay forthe telehealth services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicarerules. 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 G2025 is payment for a telehealth distant site service furnished by a rural health clinic (rhc) or federally qualified health center (fqhc) only.We find that CPT code G2025 is not supported in the medical record. Specifically, any services provided between January 27, 2020 and June 30, 2020 needs to be billed with additional codes GO466, G0467, G0468, G0469, G0470 or G2025 with modifier 95. Beginning July 1, 2020, this code could be submitted. Since this service was provided before June 30, 2020, this service should be billed with an additional code with modifer 25. Based on this information, we decided that Medicare rules for coverage of the telehealth services have not been met.Therefore, we decided that the Plan does not have to pay forthe telehealth services coded G2025 provided on May 5, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Gel-One injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no radiologic evidence of osteoarthritis.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found in this case there was no provided radiologic evidence of diagnosis of osteoarthritis (i.e. X-ray or MRI) and at least a three month trial of conservative therapy which included nonpharmacologic therapy (such as home exercise program, physical therapy, use of assistive devices) and use of simple analgesics (pain medications) and anti-inflammatories (Advil, Motrin).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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Gel-One injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the battery back-up (E1399).
You asked the Plan to pre-approve the battery backup. You say that you would like reconsideration because the
member lives in an area where the power goes out every day. The Plan denied your request. The Plan says this
is not a Medicare covered benefit
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has the continuous positive airway pressure device battery. The backup battery
serves the same purpose as the battery backup. Therefore, we decided that the Plan does not have to preapprove
the battery back-up (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Urolift procedure for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthis procedure is reserved for patients who have failed pharmaceutical treatment.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria have not been met. Specifically, failure, contraindication or intolerance to at least six months of conventional medical therapy for BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) has not been documented in the records provided.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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Urolift procedure for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hydraulic patient lift.
You asked the Plan to pre-approve a hydraulic patient lift (E0630). You say that the enrollee will be confined
to bed without a patient lift. The Plan denied your request. The Plan says there is no documentation that the
home environment is able to accommodate the lift or that the enrollee can operate the lift system.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The documentation required by the Plan was not submitted. Based on
this information, we decided that Medicare rules for coverage of a hydraulic patient lift (E0630) have not been
met. Therefore, we decided that the Plan does not have to pre-approve a hydraulic patient lift.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean additional twenty-eight (28) miles of Logisticare mileage.You asked the Plan to pre-approveadditional mileage. You say that you are requesting additional routine transportation miles to attend medical appointments.The Plan denied your request. The Plan says the service is a covered benefit but your request exceeds mileage limit.Medicare does notcover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. You are requesting an additional twenty-eight (28) miles for a total of seventy-eight (78) miles. Your benefit only allows fifty (50) miles. You have exceeded your benefit limit. This request is not covered by your health plan.Therefore, we decided that the Plan does not have to pre-approvean additional twenty-eight (28) miles of Logisticare mileage.