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

We decided that the Plan has to pay for the crown for tooth #11 provided on February 3, 2021.

You asked the Plan to pay for the crown. You say that the core buildup was paid but the crown was denied. The Plan denied your request. The Plan says that the tooth does not appear to have significant breakdown due to decay or trauma.

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 crown when the services are medically necessary and reasonable. 

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 crown. Our physician reviewer found that 60% of the coronal structure was missing. Our reviewer says that the documentation provided meets the criteria for coverage for a crown restoration for tooth #11 due to significant coronal breakdown.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pay for the crown for tooth #11 provided on February 3, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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 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 surgical treatment of a hip fracture after a fall. 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 documentation does support a need for physical and/or occupational therapy, there is no documented
need for a intensive, multi-disciplinary rehabilitation program. 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 acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on March 29, 2021.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty power scooter.
You asked the Plan to pre-approve these services. You say that the battery on the standard power scooter doesn't last long enough after two rounds of trips to the store. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a heavy duty power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, prophylaxis, and topical application of fluoride varnish provided on June 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, prophylaxis, and topical application of fluoride varnish. You say that you only saw the dental assistant on this date of service. You also say that you asked multiple times if the services would be covered, and they said if it was not that they would waive the cleaning fee. The Plan denied your request. The Plan says these services cannot be covered under the Plan for being rendered by an OON 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.
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 periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewing x-rays, prophylaxis, and topical application of fluoride varnish provided on June 14, 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 Sanexas therapy (97112) and the associated subcutaneous injections (J3415, J3490, 96372) provided October 29, 2020.
You asked the Plan to pay for Sanexas therapy and the associated subcutaneous injections. You say that these claims should be paid for medical necessity. The Plan denied your request. The Plan says the clinical value and effectiveness of the requested procedure have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that Sanexas therapy and the associated injections are subject to the criteria listed in the Medicare rules section.
Regarding the therapy services (97112), review of the file and publicly available records find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the state. Furthermore, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sanexas therapy and the associated subcutaneous injections have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas therapy (97112) and the associated subcutaneous injections (J3415, J3490, 96372) provided October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141).
You asked the Plan to pre-approve the MRI. You say that you are high-risk of congestive heart failure and you do not want to go to the emergency room. You state your heart is not in the proper condition and you desperately need this MRI. You state your health is declining rapidly and you have been in bed for more than a month unable to move your arms and legs. The Plan denied your request. The Plan says your doctor note received did not tell us if physical therapy or home exercise has been trialed. The Plan states the x-ray of your back was reported to be done but the result was not sent for review. The Plan states the office note did not tell the Plan what other activity you have performed to help with your pain. The Plan states your doctor note reported you are currently smoking and there is no information reported if ibuprofen was trialed or if there was a reason not to take medication.
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 the MRI. Our physician reviewer found the provided documentation does not clearly describe you having fully exhausted physical therapy and/ home exercises, and there is insufficient evidence of a current red flag diagnosis which might warrant earlier consideration for imaging. X-ray back was completed but not provided for review. Therefore, without sufficient support made for MRI cervical spine, this request for such will be considered not medically necessary at this time. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary and beneficial for the enrollee. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 is 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 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 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. 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 pay for the subsequent hospital care (99231) provided on July 15, 2021.
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has processed correctly.
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 99231 has a bundled relationship with code 01967 and cannot be paid as billed. 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 the subsequent hospital care (99231) provided on July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the SNF extension is medically necessary and beneficial. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are not able to move one hundred (100) feet without wheelchair and you cannot be left alone. You state you will experience muscle loss is proper care is not received. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT code 64624), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says this procedure is not approved by the enrollee's Plan because it is still being studied to see if it is as good or better than standard treatment for knee pain from osteoarthritis.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for destruction by neurolytic agent, genicular nerve branches including imaging guidance when
performed (64624) is not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not
have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance,
when performed (CPT code 64624), for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (11045) provided June 4, 2021.
You asked the Plan to pay for the debridement services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there is insufficient information provided to corroborate the procedures performed.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the debridement services (11045) provided June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and cone beam computed tomography (CT) capture and interpretation (D0366) provided on June 21, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation and cone beam CT capture and interpretation. You say that it was recommended that you get an implant because the long-term benefit of an implant is a much better solution than other procedures that are covered. You also say that you are retired, your only income is social security, and you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 comprehensive periodontal evaluation (D0180) and cone beam computed tomography (CT) capture and interpretation (D0366) provided on June 21, 2021