Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following elective surgery.

You asked the Plan to pre-approve acute inpatient hospital care. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says there is no medical need for inpatient care following the approved elective surgery.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the review indicates that the enrollee has a history of hypertension, hypothyroidism, chronic left upper extremity numbness and tremors, C2-C6 fusion. He is undergoing a planned total shoulder arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under code 23472 is not listed on the Medicare Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review indicates that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care following elective surgery.
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 IRF care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 patient was admitted for lumbar spinal surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 11, 2021, to April 15, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department with mental status changes. She was evaluated by wound care and discharged when considered medically stable. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from April 11, 2021, to April 15, 2021.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Durolane. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that step therapy, as outlined by the Plan, requires that preferred viscosupplements, Othovisc and Monovisc, be trialed first. The enrollee has tried and failed Monovisc. The documentation does not outline contraindications or reasons that Orthovisc was not considered or that the Plan's additional required drug would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.

You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your
request. The Plan says this is the responsibility of the enrollee's prescription drug plan when provided by a
pharmacy.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Synvisc.

Benefits for Synvisc may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the laparoscopy services provided on December 29, 2020.

You asked the Plan to pay for the laparoscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that these services are being denied due to not covered for diagnosis indicated and the submitted code is disallowed because the procedure code is unlisted or by report only, no records are attached. It appears the diagnosis code billed with this service was E66.01 defined as morbid (severe) obesity due to excess calories. The documentation does not support why the diagnosis code billed is not covered. Therefore, we decided that the Plan has to pay for the laparoscopy services provided on December 29, 2020.

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 a single supported porcelain/ceramic crown (D6058), provided by an out-of-network provider on April 1, 2021.
You asked the Plan to pay for a single supported porcelain/ceramic crown. You say that you should not have to change your dentist because Medicare says so. The Plan denied your request. The Plan says services are not covered due to the provider being out-of-network.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a single supported porcelain/ceramic crown (D6058), provided by an out-of-network provider on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on February 1, 2021.
You asked the Plan to pay for drug testing. You say that this test is covered by Medicare and was ordered by a treating physician who made the professional determination of medical necessity. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the record does not support the code billed on this claim.
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 G0483 is drug test(s), definitive; qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolites if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not support that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042), bone debridement (11044), chemical cauterization of granulation tissue (17250), and subsequent nursing facility care (99308) provided on June 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the debridements, chemical cauterization of granulation tissue, and subsequent nursing facility care (99308). You say that these services were rendered due to medical necessity and patient care was provided on an urgent request to avoid wound complications. The Plan denied your request. The Plan says these services were not provided on an emergency basis, and there are in-network providers available.
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 subcutaneous tissue debridement (11042), bone debridement (11044), chemical cauterization of granulation tissue (17250), and subsequent nursing facility care (99308) provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) and occupational therapy (OT) services provided from May 20, 2021, to May 31, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the PT and OT services. You say that you would like to appeal these services. The Plan denied your request. The Plan says the treating provider is not a network provider, and the services were not referred by a network provider. The Plan also says that these services were 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 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 (PT) and occupational therapy (OT) services provided from May 20, 2021, to May 31, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00811 provided on February 11, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 00811 is anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified.

We find that CPT code 00811 is not supported in the medical record. Specifically, this service billed was previously processed and paid by the Plan. This means that this code billed is considered a duplicate. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00811 provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a continuous glucose monitor received on April 1, 2021.
You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. The Plan says that there is a non-valid physician order, and a lack of supporting information in medical records to support the codes billed.
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the monitor. Our reviewer says that the
requested services are medically reasonable and necessary. Our physician reviewer found the enrollee is on multiple daily injections of insulin, and adjusts the doses based on the checking the levels four times a day. There is a diagnosis of diabetes mellitus. The enrollee was seen in August 20020, November 2020, and February 2021. 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 monitor have been met. Therefore, we decided that the Plan has to pay for a continuous glucose monitor received on April 1, 2021.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says the records do not address why a standard wheelchair is not appropriate.
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 wheelchair. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found based on the medical records provided, there is documentation of difficulty with ambulation,
but there is no clear documentation of limitations with specific mobility-related activities of daily living such as
toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The provided records
do not clearly specify that the mobility deficit cannot be resolved by a cane and/or walker. The records do not
clearly indicate that the enrollee's home is appropriate for the wheelchair.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lightweight manual wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodontal maintenance. You say that you paid the provider $700 in cash. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.
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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210), and osseous tissue regeneration biological materials (D4265) provided by an out-of-network provider on May 7, 2021.
You asked the Plan to pay for a tooth extraction and osseous tissue regeneration biological materials. You say that you were unaware that you did not have out-of-network provider coverage. The Plan denied your request. The Plan says the services are not covered when provided by an out-of-network provider.
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 a tooth extraction and osseous tissue regeneration biological materials when the services are provided by an in-network provider.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction and osseous tissue regeneration biological materials have not been met. Specifically, the services at issue were received by an out-of-network provider Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210), and osseous tissue regeneration biological materials (D4265) provided by an out-of-network provider on May 7, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need to get to a medical appointment. 
The Plan denied your request. The Plan says your benefit only allows 24 one-way trips with each one-way trip 
not exceeding 50 miles of driving distance. 
 
Medicare does not cover 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. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 68 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage (A0170).