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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 continues to exhibit septic physiology. The enrollee is not clinically
stable. 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 he is not currently receiving but that would be
available at the LTACH facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan and physiologic study.
You asked the Plan to pre-approve limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) (93922) and duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925). You say that the enrollee needs the procedures. The Plan denied your request. The Plan says the clinical notes do not establish the medical necessity for the requested procedures.
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 a duplex scan and physiologic study Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have symptoms of peripheral vascular ischemia. There are no physical examination findings of vascular abnormality in the lower bilateral legs (absence of marked diminution of pulses, pallor, numbness, coolness of an extremity or signs of vascular obstruction. There is no mention of claudication, arteriovenous malformation, aneurysm, lower extremity trauma, rest pain, gangrene or recent post-operative vascular conditions. The review has determined that the requested procedures are not medically reasonable or necessary. The enrollee does not meet LCD criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) (93922) and duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925) have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan and physiologic study.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccination (0002A) provided April 29, 2021.
You asked the Plan to pay for the vaccination. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the claim must be billed to original Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare payment for COVID vaccinations administered during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS program. We looked at the file and Medicare rules. The claim is for a COVID vaccine. This claim must be submitted to original Medicare for payment. Based on this information, we decided that Medicare rules for coverage of the vaccination have not been met. Therefore, we decided that the Plan does not have to pay for a vaccination (0002A) provided April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve factor 5 Leiden testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary based on your current diagnosis and current health. The Plan denied your request. The Plan says this test is clinically efficacious.
The Plan must follow Medicare rules. Medicare rules say that F5 gene testing is not considered medically necessary. The requested testing is statutorily not covered at this time. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve factor 5 Leiden testing.
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 plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 required minimal to total assistance for upper body and lower body 
dressing. The enrollee required total assistance to transfers to bed.  

The enrollee required maximum/total assistance to lie down. The documentation does not support that the 
enrollee required the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, 
or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The 
enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 30 additional routine transportation trips to medical appointments in the current year.
You asked the Plan to provide additional routine transportation. You say that you rely on these transportation services to get to your appointments. The Plan denied your request. The Plan says your supplemental transportation benefit covers 52 trips, 30 of which may be used for transportation to network physicians, medical facilities and pharmacies. You have used all 30 trips for these purposes. Extra trips are not covered by this benefit.
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 a maximum of 52 trips per year. 30 of these trips may be used for transportation to network physicians, medical facilities and pharmacies. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 30 additional routine transportation trips to medical appointments in the current year.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (93042) provided to the enrollee on March 17, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed.
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, we have confirmed that code 93042 has a bundled relationship with code 12013 and cannot be paid as billed without the required modifier. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (93042) provided to the enrollee on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80053, 80061, 81000, 82306, 82607, 82728, 82746, 83036, 83090, 83540, 83550, 83970, 84270, 84403, 84439, 84443, 84481, 84550, 85025, 85651, 86003, 86141, 86431) provided on December 15, 2020.
You asked the Plan to pay for laboratory services. You say that this testing was ordered by an in-network provider. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (80053, 80061, 81000, 82306, 82607, 82728, 82746, 83036, 83090, 83540, 83550, 83970, 84270, 84403, 84439, 84443, 84481, 84550, 85025, 85651, 86003, 86141, 86431) provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and partial lower denture (D5214) provided on April 13, 2021.
You asked the Plan to pay for the dental services. You say that you were advised you would receive $1,000 for the annual maximum amount plus $58 and $120. You also say that you feel these services should be covered. The Plan denied your request. The Plan says dentures are not covered by Medicare.
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 the complete upper denture (D5110) and partial lower denture (D5214) provided on April 13, 2021.
Your complaint about being incorrect information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has had minimally invasive lumbar decompression at L3-L4 and L4-l5, the levels requested for treatment. The Superion Interspinous Spacer is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative treatment. The Superion Interspinous Spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5.
The Food and Drug Administration states that the requested procedure is contraindicated if a decompression
procedure at the index level has been performed. The elements of the coverage criteria are not satisfied.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
August 30, 2020 to September 28, 2020.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied
your request. The Plan says there is not a visit billed on the first date of service.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered. In addition to reporting a visit line using the G
codes, agencies must report an additional line item with the same revenue code and date of service, reporting
one of the three Q codes.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, while a Q
code was billed on the claim, it was not billed with the same date of service as a G code as required. Therefore,
we decided that the Plan does not have to pay for the home health services provided to the enrollee from
August 30, 2020 to September 28, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the nail debridement (11721) and trimming of skin lesion (11055) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the nail debridement and trimming of skin lesion. You say that these services are medically necessary for your condition. The Plan denied your request. The Plan says there are providers in-network available to treat your medical condition.
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 the nail debridement (11721) and trimming of skin lesion (11055) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip magnetic resonance imaging (MRI).
You asked the Plan to pre-approve hip MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 hip MRI. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has lumbar back pain with radiculopathy. The record indicates that the enrollee is undergoing physical therapy. No recent injury is noted. The medical records provided do not support the medical necessity and reasonableness of the requested service. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hip MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve hip magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this outpatient procedure minimizes tissue damage 
and blood loss, allowing for a faster, more comfortable recovery. The Plan denied your request. The Plan says 
the services are considered experimental and investigational. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the 
enrollee.
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's current level of function and poor endurance to tolerate activity, does 
not require an intensive, complex, multidisciplinary approach to daily therapy. The enrollee's rehab needs can 
be safely met in an alternate and low intensity setting such as a skilled nursing facility. 
 
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.