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

We decided that the Plan does not have to pre-approve a ridge preservation graft (D7953) and gingival irrigation (D4921).

You asked the Plan to pre-approve a ridge preservation graft and gingival irrigation. You say that you are in pain and cannot eat. The Plan denied your request. The Plan says these services are not covered.

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 ridge preservation graft (D7953) and gingival irrigation (D4921).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after September 30, 2021.

You asked the Plan to pre-approve SNF care. You say that the enrollee is very unstable and needs more time to increase mobility. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after September 30, 2021 is correct.

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 enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after September 30, 2021.
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 this is a safe and effective procedure which is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this is helpful for treatment of 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 this is considered an experimental/investigational procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that that the member requires hospital resources of a scope, duration, frequency and amount which are not provided or do not exist at a lower level of care. The Plan denied your request. The Plan says a LTACH admission is not medically necessary. The enrollee's medical needs are being met in the current acute setting.
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 that the enrollee was admitted with hypoxic respiratory failure due to Coronavirus illness. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has coronavirus, and this is the only hospital that will accept coronavirus patients. The Plan denied your request. The Plan says the stay 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 the enrollee was admitted with coronavirus infection. The enrollee continues to require oxygen and is unable to be placed in rehabilitation facilities in New York state. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a buccal or labial frenectomy (frenulectomy) (D7961).
You asked the Plan to pre-approve the dental service. You say that your dentist advised that you need this service. You say that you need this service so you can get an upper denture. You also say that you have no upper teeth, and it is hard for you to eat or talk. The Plan denied your request. The Plan says a frenectomy procedure is excluded from coverage.
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 frenectomy procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a buccal or labial frenectomy (frenulectomy) (D7961).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology consultation for ultrasound therapy to be provided out-of-network.
You asked the Plan to pre-approve the out-of-network neurology consultation.. You say that you would like reconsideration because there are no local in-network providers available to render this therapy. The Plan denied your request. The Plan says the requested treatment is not noted to be medically necessary.
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 out-of-network neurology consultation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is only reserved for refractory essential tremor when a series of additional requirements are met. It is not clear in this case that you would otherwise be an appropriate candidate for the requested treatment at this time. In as much there is not necessarily a need for out-of-network services to be covered as it cannot otherwise be determined that the requested therapy would be medically necessary covered 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 the out-of-network neurology consultation. have not been met. Therefore, we decided that the Plan does not have to pre-approve the neurology consultation for ultrasound therapy to be provided out-of-network
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) provided in an inpatient hospital facility.
You asked the Plan to pre-approve a TAVR. You say that you have documentation stating that you have been diagnosed with aortic insufficiency by your doctor and services are medically necessary. The Plan denied your request. The Plan says your records do not show you have a narrowing of the valve in your heart, which is the only approved indication for this procedure at this time.
The Plan must follow Medicare rules. Medicare rules say that enrollees must be enrolled in a Coverage with Evidence Development (CED) study or a clinical trial in order to have this covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for TAVR have not been met. Specifically, the record does not show that you are receiving the service under Coverage with Evidence Development (CED) or a Medicare-approved clinical study. Therefore, we decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) provided in an inpatient hospital facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmologist office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an ophthalmologist office visit. You say that you would like to continue your care with this ophthalmologist. The Plan denied your request. The Plan says there are ophthalmology specialist in the Plan's network who can provide the requested service.
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 an ophthalmologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for the inpatient services. We decided that the Plan does not have to pay for .

You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan says that the services are not payable as billed.

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 A41.9, defined as sepsis, unspecified organism, R53.2, defined as functional quadriplegia, N39.0, defined as urinary tract infection, site not specified), N17.9 defined as acute kidney failure, unspecified, and E87.2 defined as acidosis. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the enrollee's white blood cell count was normal, lactate level was normal, and the procalcitonin level was elevated. Blood cultures were obtained, and antibiotics were administered.

We decided that the Plan has to pay for the inpatient services with the diagnosis codes R53.2 (functional quadriplegia), N17.9 (acute kidney failure, unspecified), ad E87.2 (acidosis).

The physical examination revealed bilateral upper extremity contractures, bilateral upper and lower extremity atrophy, and functional quadriplegia. The enrollee's blood urea nitrogen (BUN) and creatinine were elevated, with documentation of acute renal failure superimposed on chronic renal failure.

We also decided that the Plan does not have to pay for the diagnosis codes A41.9 (sepsis, unspecified organism) and N39.0 (urinary tract infection, site not specified).

The documentation is insufficient to support a diagnosis of sepsis, unspecified organism. The documentation does not support that a urinary tract infection was identified.

This means the documentation partially supports the DRG billed for the inpatient services provided May 31, 2019 to June 13, 2019.

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: 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 would like the IRF admission covered. The Plan denied your request. The Plan says admission to IRF was denied as not meeting IRF criteria, not medically necessary, and a lower level of care might be appropriate.
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 that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutritional counseling, dietitian visit (S9470).
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are appealing the
denial for the requested service. You believe that the provider can help you with your conditions. The Plan
denied your request. The Plan says the enrollee does not meet the criteria as the records do not indicate that you
have diabetes or kidney disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does
not have to pre-approve nutritional counseling, dietitian visit (S9470).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 1, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that the doctor missed two skin cancers and the staff was rude. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on December 1, 2020.
We note your complaint that the providers staff were rude. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental service. You say that in the past 2 years you have had 7 teeth removed. You say that your dentist has recommended a partial denture. You also say that a partial means that your health may be restored. The Plan denied your request. The Plan says prosthodontic services, including a partial denture, are excluded from coverage.
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 partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.

You asked the Plan to pre-approve 12 additional physical therapy visits. You say that this therapy is necessary
to treat your temporomandibular joint (TMJ) syndrome. The Plan denied your request. The Plan says you can
be treated with a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary 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 12 additional physical therapy visits. 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 the records show that you have received manual therapy and reported complete relief of pain. You have been given home exercise program to continue managing your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas NeoGEN-Series Therapy and Nutri-Pharmaceutical blend injections represented by CPT codes 97112, 97032, 97016, 96372, J3490, J3420, J3415, J3411, J1955 on September 1, 2020.

You asked the Plan to pay for the Sanexas NeoGEN-Series Therapy and Nutri-Pharmaceutical blend injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says experimental or investigational services are not covered.

The Plan must follow Medicare rules. Medicare rules say that Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas NeoGEN-Series Therapy and Nutri-Pharmaceutical blend injections have not been met. Specifically, review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Virginia. Additionally, The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the Sanexas NeoGEN-Series Therapy and Nutri-Pharmaceutical blend injections represented by CPT codes 97112, 97032, 97016, 96372, J3490, J3420, J3415, J3411, J1955 on September 1, 2020.