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

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and caries risk assessment and documentation (D0602) provided on July 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and caries risk assessment and documentation. You say that you confirmed with your dentist that they accepted your insurance and were in-network. The Plan denied your request. The Plan says these services were rendered by a non-network provider. The Plan also says that services rendered by a provider who is not in network 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and caries risk assessment and documentation (D0602) provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation of the lumbar spine.  You asked the Plan to pre-approve radiofrequency ablation of the lumbar spine. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs.  We looked at the file and Medicare rules. In this case, the record indicates that at this time only 1 medically reasonable and necessary diagnostic MBB has been performed. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hardware removal and transforaminal interbody lumbar fusion.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation in the submitted records of adequate conservative measures for the enrollee's back pain, including physical therapy. The records do not support that the criteria for back hardware removal and L1-2 fusion are met. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve hardware removal and transforaminal interbody lumbar fusion.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve open and minimally invasive fusion surgery of the sacroiliac joint.  You asked the Plan to pre-approve open and minimally invasive fusion surgery. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that the imaging procedures documented in the Medicare rules section must have occurred before this surgery will be approved.   We looked at the file and Medicare rules. In this case, there is no evidence of the requested imaging documentation as having been performed. Based on this information, we decided that Medicare rules for coverage of open and minimally invasive fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve open and minimally invasive fusion surgery of the sacroiliac joint.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 and regular physician evaluation. Your 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-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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there are no complex rehabilitation needs.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for bilateral leg weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve presbyopia-correcting (P-C) intraocular lenses (IOL).  You asked the Plan to pre-approve a P-C IOL. You say that this service is medically reasonable and necessary. The Plan denied your request. The Plan says neither the Plan nor Medicare covers this service.  The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL.   While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve presbyopia-correcting (P-C) intraocular lenses (IOL).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says failure to document the patient's response to a four-week trial of consistently applied conservative measures (dates are missing) and the fact that these measurements seem to show evidence of significant improvement means the patient does not meet criteria for a standard PCD.  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 therapy demonstrating 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 pre-approve a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power seat elevation system, push handles, back up camera, and electronic connection between the wheelchair controller and two or more power seating system motors.  You asked the Plan to pre-approve power seat elevation system, push handles, back up camera, and electronic connection between the wheelchair controller and two or more power seating system motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that a power seat elevation feature is non-covered. The rules also say that   The requested power seat elevation feature is non-covered. The requested push handles and back up camera at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Review of the file shows that the enrollee is independent with feeding and the enrollee's upper limb strength and function are described as adequate for them to be able to control the approved power options using their own switches (which are included in the allowance of the power options).  Therefore, we decided that the Plan does not have to pre-approve power seat elevation system, push handles, back up camera, and electronic connection between the wheelchair controller and two or more power seating system motors.
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 SNF services. You say that a SNF admission is medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically necessary.  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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for a urinary tract infection. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at a standby assist level with functional mobility including gait to 150 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for 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 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-approve the low vision glasses.  You asked the Plan to pre-approve the low vision glasses. You say that the member was diagnosed with bilateral retrolental fibroplasia, bilateral cataracts and bilateral aphakia. You say that traditional cataract surgery was performed in 1974 on the left and in 1979 on the right eye. The Plan denied your request. The Plan says low vision glasses are not covered.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 for routine eyewear.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the low vision glasses have not been met. Specifically, low vision glasses are not considered routine eyewear. Therefore, we decided that the Plan does not have to pre-approve the low vision glasses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4211) provided on May 12, 2021.  You asked the Plan to pay for the gingivectomy or gingivoplasty (D4211). You say that this is an incorrect code denial. The Plan denied your request. The Plan says the 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 pay for the gingivectomy or gingivoplasty (D4211) provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power seat elevation system (E2300), expandable controller (E2377), harness (E2313), and electronic connection (E2311).  You asked the Plan to pre-approve the power seat elevation system, expandable controller, harness, and electronic connection. You say that the items are medically necessary. The Plan denied your request. The Plan says the power seat elevation system does not serve a medical purpose and there is no medical need to control power options through a joystick.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    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 for the expandable controller, harness and electrical connection. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no documentation indicating a medical need to control power options through a joystick.  The items at issue in this appeal do not serve a purpose that is primarily medical in nature or medically necessary. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300), expandable controller (E2377), harness (E2313), and electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3000).  You asked the Plan to pre-approve foot orthotics. You say that the requested item was helpful to you in the past. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis.  You asked the Plan to pre-approve a knee orthosis. You say that the service is 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 a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s).  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 knee orthosis. Our reviewer says that the item is not medically necessary. Our physician reviewer found the record does not indicate that the enrollee has had recent injury or surgery upon the knee. The record does not indicate the presence of instability. The elements of the coverage criteria are not satisfied. The requested service is not 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 a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for pontic-porcelain/ceramic (D6245) and a retainer crown (D6750) provided by a participating provider.  You asked the Plan to pay for pontic-porcelain/ceramic and a retainer crown. You say that the doctor thinks this is your best option for repair. The Plan denied your request. The Plan says that the services being provided are not covered 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. The Plan covers pontic-porcelain/ceramic and a retainer crown.  We looked at the file and Medicare rules. Based on this information, pontic-porcelain/ceramic and a retainer crown are covered benefits. Therefore, we decided that the Plan has to pay for pontic-porcelain/ceramic (D6245) and a retainer crown (D6750) provided by a participating provider.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve nasal/sinus endoscopy services (31295 and 31298).  You asked the Plan to pre-approve the nasal/sinus endoscopy services. You say that the enrollee is in and out of the hospital, is not able to leave her home, and is suffering. You also say that the enrollee cannot financially cover these services. The Plan denied your request. The Plan says these procedures you are requesting do not meet the requirements for approval.  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 nasal/sinus endoscopy services. Our reviewer says that there is no documentation that the nasal/sinus endoscopy services (31295 and 31298) at issue in this case meet Medicare criteria for medically reasonable and necessary Our physician reviewer found the provided records do not show evidence of chronic sinusitis on computed tomography or endoscopic examination.  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 nasal/sinus endoscopy services have not been met. Therefore, we decided that the Plan does not have to pre-approve nasal/sinus endoscopy services (31295 and 31298).