Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Inogen G4 portable oxygen concentrator (POC).You asked the Plan to pre-approvea portable oxygen concentrator. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not medically necessary.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygenin the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  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 portable oxygen concentrator. Our reviewer says that the documentation does not support that the requested POC is medically reasonable or necessary. Our physician reviewer found the documentation provided does not include any measurements of oxygenation, either at rest or with exertion, so the medical necessity of home oxygen is not established. There is no documentation that supplemental oxygen during exertion is needed, and no indication ofwhy standard portable compressed oxygen tanks would not be sufficient, if the enrollee did require portable oxygen. Therefore, the enrollee does not meet criteria for the requested POC. 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 portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approvean Inogen G4 portable oxygen concentrator (POC)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for partial foot, shoe insert with longitudinal arch, toe filler (L5000) diabetic, total contact, custom fabricated, multiple density, removable inlay (A5513) provided April 21, 2020.
You asked the Plan to pay for the orthotics. You say that all documents support the enrollee receiving diabetic shoes with inserts and toe filler. Please review the documents and process the claim according to the enrollee's policy. The Plan denied your request. The Plan says the records do not support the billed service.
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 physician order and an itemized shipping/billing invoice to indicate the specific supplies provided in this case. 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 partial foot, shoe insert with longitudinal arch, toe filler (L5000) diabetic, total contact, custom fabricated, multiple density, removable inlay (A5513) provided April 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional physical therapy services.You asked the Plan to pre-approveadditional physical therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medicallynecessary outpatient therapy.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 additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had extensive therapy for your condition and it does not appear that you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in an independent exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. Therefore, you do not meet criteria for the requested 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 additional physical therapy services have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 2 and 14.
You asked the Plan to pre-approve the dental services. You say that the requested crowns are necessary to establish contact. The Plan denied your request. The Plan says services considered not reasonable or necessary are not covered under any condition.
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 dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the crowns for teeth # 2 and 14 are not medically necessary. Our physician reviewer found the provided documentation indicates the presence of a crown on tooth # 14 and a restoration in tooth #2. The reviewer found that these appear adequate. Therefore, the reviewer found that the requested crowns for teeth # 2 and 14 are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 2 and 14.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion Vertiflexprocedure.You asked the Plan to pre-approveInsertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869). You say that this procedure is medically necessary to relieve the enrollee's back pain.The Plan denied your request. The Plan says there is not enough medical evidence that shows the Superion Vertiflex Procedure is safe and helpful.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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869). Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show 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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup services and periodontal scaling and root
planing services.
You asked the Plan to pre-approve core buildup services and periodontal scaling and root planing services. You
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
requested services are not a covered 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 core
buildup services and periodontal scaling and root planing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the enrollee needs a pneumatic compression device to help with swelling of the legs.The Plan denied your request. The Plan says criteria is notmet for a pneumatic compression device.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapydemonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to providea pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on June 5, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only incases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forphysician services provided on June 5, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet injections.
You asked the Plan to pre-approve diagnostic facet injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that diagnostic facet injections are only covered for certain indications. 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 diagnostic facet injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is status post multi-level lumbar laminectomy and has arachnioditis/adhesions and a lipoma in the lumbar spine. Also noted on MRI are facet arthropathy at multiple levels. The requested injections are to be performed at the levels of prior surgery. This does not meet the criteria of the LCD. Therefore, the enrollee does not meet criteria for the requested 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 diagnostic facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicarerules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect 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 enrollee required minimal assistance to don socks while seated. The enrollee required moderate assistance times two to stand up and sit down. The enrollee required maximum assistance times two for bed to chair transfer. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 is in no condition to take care of himself. The Plan denied your request. The Plan says it is not expected the enrollee will need more than 25 days of acute care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for colon cancer. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 referral for an out-of-network consultation and
treatment for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the provider is not part of the network.
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
a referral for an out-of-network consultation and treatment for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is in isolation and you have been receiving close monitoring for any signs and symptoms of fever, hypoxia, GI symptoms or respiratory distress. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.
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 the SNF services. Our reviewer says that daily skilled services are not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. The medical records provided that the enrollee does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. As a practical matter, the enrollee does not require the services on an inpatient basis, in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveconsultation -diagnostic  service  provided  by dentist (D9310) and removal  of torus  mandibularis  (D7473).You asked the  Plan to pre-approveconsultation -diagnostic  service  provided  by dentist  and removal  of torus mandibularis.  You say that the service  is  medically  necessary.The  Plan  denied  your  request.  The  Plan  says this service  is  not a covered 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-approveconsultation -diagnostic  service  provided  by dentist  (D9310)  and removal  of torus  mandibularis  (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forinterim partial denture (D5820) provided on September 1, 2020.You asked the Plan to pay forinterim partial denture. You say that the services were medically necessary.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicarecoverage. 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 pay forinterim partial denture (D5820) provided on 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.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs additional rehab. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 6, 2020 with a urinary tract infection. The physical therapy note states she needs maximum assistance for bed and chair transfers and is unable to tolerate walking due to weight bearing status. She does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate 15 hours per week of rehabilitative services with regular physician evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve the imaging. You say that due to COVID, you could not have a stress test in
July. The Plan denied your request. The Plan says there are no signs of sickness.
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 imaging. Our reviewer says that the
requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer
found
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 imaging have not been met. Therefore, we decided that the Plan does not
have to pre-approve myocardial perfusion imaging.