Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. 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 radiofrequency ablation used for sacro-iliac joint pain
is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed
radiofrequency.
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 radiofrequency ablation. Our reviewer
says that the services are not medically necessary. Our physician reviewer found radiofrequency ablation for
denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered
investigational and therefore, not medically 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided from January 2, 2021, to January 6, 2021.
You asked the Plan to pay for home infusion therapy. You say that this is supported by the nursing notes. The Plan denied your request. The Plan says this is not a valid 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 99601 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided from January 2, 2021, to January 6, 2021
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0637) provided March 17, 2021.
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the item was provided following an unsolicited telehealth consult. Coverage rules have not been met.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L0637) provided March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on April 28, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. You say that you only required replacement lenses and not frames and you think it's ridiculous to pay for each lens. The Plan denied your request. The Plan says the Plan paid the vision benefit amount of $250.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a limit of $250 for eye wear every 2 calendar years.
We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum vision benefit of $250, and you are responsible for costs above the plan limit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 30, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 28485 is not supported.
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, the CPT Code Manual definition of code 28485 is open treatment of metatarsal fracture, includes internal fixation, when performed, each. We find that CPT code 28485 is not supported in the medical record. Specifically, there is no documentation of open treatment of metatarsal fracture with internal fixation. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 30, 2021.
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 requested admission to an IRF is medically
necessary.
The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 4, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99285 is not supported.
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, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity. We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support
the Level 5 complexity of services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 4, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room (ER) visit you had on April 22, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this copayment should be waived because you were admitted within three days. The Plan denied your request. The Plan says that this copayment was charged correctly because you were not admitted as an inpatient. The Plan claims that you were kept in observation instead.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees pay a $90 for emergency room services, but that copayment is waived if you are admitted for the same condition within three days. The Plan alleges that you were not admitted to the hospital, but rather kept in observation. We do not find that argument persuasive. Throughout your medical records, it states that you were admitted. When you were discharged from the emergency room on April 23, 2021, the medical records explicitly state that 'the patient is admitted to general surgery for further evaluation and management'. Nowhere in the records does it state that you were kept in observation status. In fact, the medical records from your hospital stay include numerous pages where the heading states "Inpatient H&P (history and physical)". Again, the records also note that you were in the acute care surgery department and no mention of observation is found within the record. Finally, on the actual discharge summary, the heading in your medical records says 'Inpatient Discharge Summary.' Based on the foregoing, we can only conclude that you were admitted as an inpatient. The Plan also failed to provide any claims documents showing that this hospitalization was billed as an observation or outpatient stay.
Looking at the totality of the evidence, it appears that you were admitted as an inpatient within three days of this ER visit. Therefore, we decided that the Plan has to waive the copayment for the emergency room (ER) visit you had on April 22, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150), bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), panoramic
radiographic image (D0330), and topical application of fluoride varnish (D1206) provided March 24, 2021 by
an out-of-network (OON) provider.

You asked the Plan to pay for the comprehensive oral exam, bitewing x-rays, dental cleaning, panoramic x-rays
and fluoride varnish. You say that the provider should be in-network.

The Plan denied your request. The Plan says the provider was previously in-network at a different office
location but is not a participating provider at the current location in the year 2021. The services were correctly
denied because the provider was OON at the time of the services.

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 exam, bitewing x-rays and dental cleaning once per year.

We looked at the file, and Medicare rules. The services in this case were provided by an OON dental provider.
Additionally, though the Plan offers dental benefits in excess of Medicare coverage, the panoramic x-rays and
fluoride varnish are not among those covered services. Therefore, we decided that the Plan does not have to
pay for the comprehensive oral evaluation - new or established patient (D0150), bitewings - four radiographic
images (D0274), prophylaxis - adult (D1110), panoramic radiographic image (D0330), and topical application
of fluoride varnish (D1206) provided March 24, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), surgical placement of implant body: endosteal implant on tooth #22 D6010), guided tissue regeneration - resorbable barrier per site on tooth# 22 (D4266), bone replacement graft for ridge preservation per site on tooth #22 (D7953), and overdenture - complete mandibular (D5865).

You asked the Plan to pre-approve removal of torus mandibularis, surgical placement of implant body: endosteal implant on tooth #22, guided tissue regeneration - resorbable barrier per site on tooth# 22, bone replacement graft for ridge preservation per site on tooth #22, and overdenture - complete mandibular. You say that the services are necessary. 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 removal of torus mandibularis (D7473), surgical placement of implant body: endosteal implant on tooth #22 D6010), guided tissue regeneration - resorbable barrier per site on tooth# 22 (D4266), bone replacement graft for ridge preservation per site on tooth #22 (D7953), and overdenture - complete mandibular (D5865).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on March 11, 2021 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.

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 Plan had network providers available who could have provided 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 for the physical therapy services provided on March 11, 2021 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monovisc.

You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that monovisc is covered for the indications established in the applicable LCD. 

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 Monovisc. Our reviewer says that monovisc is not medically reasonable and necessary in this case. Our physician reviewer found that no radiographic reports confirming osteoarthritis of the knee are included in the available medical records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve monovisc.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 18, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with an incorrect code.

The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1,
2007 and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be
integrated into the OPPS OCE.

We looked at the file and Medicare rules. Per the OCE data files, the use of a code with a status indicator of
"B" will produce Edit 62, which requires the claim to be returned to the provider. As such, the outpatient
hospital claim is not payable as billed.

Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for the services provided on October 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).

You asked the Plan to pre-approve a partial lower denture. You say that the item is necessary. The Plan denied
your request. The Plan says the benefit has been exhausted.

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 partial
dentures once every five years.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a partial lower denture have not been met. Specifically, you received a partial lower denture on
August 6, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture
(D5214).