Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON
provider.
You asked the Plan to pre-approve OON services. You say that you need physical therapy closer to home. The
Plan denied your request. The Plan says service is available within the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 were able to confirm that the Plan has
contract providers located within reasonable distance and travel time from your home who can provide the
services at issue.
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 physical therapy services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft in conjunction with periradicular surgery (D3428).
You asked the Plan to pre-approve the bone graft. You say that you cannot afford to pay for this service. The Plan denied your request. The Plan says this 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 pre-approve a bone graft in conjunction with periradicular surgery (D3428).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ventilator (E0466).
You asked the Plan to pre-approve the ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that Our physician reviewer found 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and three extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the consultation and extractions. You say that you need the extractions. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and three extractions to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint fusion procedure (27279).

You asked the Plan to pre-approve the SI joint fusion procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that the SI joint fusion procedure is subject to the criteria listed 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 the SI joint fusion procedure. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found criteria for SI joint fusion not met. There is no radiographic instability fracture or lesion. SI joint fusion for degenerative conditions remains experimental. 

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 SI joint fusion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the sacroiliac (SI) joint fusion procedure (27279).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric treatment.
You asked the Plan to pre-approve continued inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the
patient requires active treatment.
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 continued inpatient psychiatric
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based
upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient
mental health treatment beyond the date in question of November 3, 2021, forward and could have been treated
in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual
hallucinations, or delusions. He was not showing any behaviors or aggression and was being cooperative and
compliant while not showing any acute threats to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient psychiatric treatment have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued inpatient psychiatric treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of October 1, 2021, forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation. He does have auditory and visual 
hallucinations but was not showing any aggressive behaviors while being cooperative and compliant. He was 
not having command hallucinations or internal preoccupation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital 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 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 admission are met in this case. Our physician reviewer found the review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital 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 acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the kyphoplasty procedure (22513).
You asked the Plan to pre-approve the kyphoplasty procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that the kyphoplasty is subject to the criteria listed 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 the kyphoplasty procedure. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the specific coverage criteria as referenced in the LCD are not met. Specifically, the records do not show that this is a new fracture that is less than 6 weeks old. 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 kyphoplasty procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the kyphoplasty procedure (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all
components and accessories, custom fabricated (L8702).
You asked the Plan to pre-approve the brace. You say that the item is medically necessary. The Plan denied
your request. The Plan says the item is 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 the brace. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
there were no records from any physicians who had physically evaluated the enrollee and stated that this device
was appropriate or recommended, and there were no records from any therapists who had treated her and
recommended this device. Further, there was no trial of this device or a similar device, showing that the
enrollee could use this device and benefit from it.
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 brace have not been met. Therefore, we decided that the Plan does not have
to pre-approve the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or
double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
(L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital 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 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 admission are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital 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 acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expanded controller, harness, and electronic 
connection device for a power wheelchair. 
 
You asked the Plan to pre-approve expanded controller, harness, and electronic connection. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization 
for these components is correct, because the enrollee's upper limb strength and function are adequate to be able 
to control the power options using their own switches. 

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 expanded controller, harness, and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the documentation does not show that the 
enrollee requires other types of proportional or non-proportional input devices. The enrollee does not need to 
operate 3 or more powered seating actuators through the drive control, a separate display, other electronic 
devices, or an attendant control. The enrollee's function in the upper extremities supports that the enrollee can 
control any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expanded controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expanded controller, harness, and 
electronic connection device for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder arthroscopy with placement of an InSpace
implant.
You asked the Plan to pre-approve shoulder arthroscopy with placement of an InSpace implant. You say that
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been
established. Therefore, coverage criteria have not been met.
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 shoulder arthroscopy with placement of
an InSpace implant. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the InSpace implant remains experimental
is shoulder surgery. 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 shoulder arthroscopy with placement of an InSpace implant have not been met.
Therefore, we decided that the Plan does not have to pre-approve shoulder arthroscopy with placement of an
InSpace implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the inpatient care provided from July 8, 2020, to July 12, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that cervical stenosis was the principal diagnosis during this admission and diagnosis related group (DRG) should remain as DRG 472. The Plan denied your request. The Plan says the documentation does not support the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code M48.02, spinal stenosis, cervical region, as the primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with ICD-10-CM code M48.02, spinal stenosis, cervical region. 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 an additional amount for the inpatient care. Our reviewer says that the primary diagnosis of spinal stenosis, cervical region, is not supported. Our physician reviewer found the enrollee was was hospitalized for neck pain radiation to arms requiring surgery. The medical records do not support the billing of ICD-10-CM code M48.02, spinal stenosis, cervical region, as the primary diagnosis. The reviewer found also found that the more appropriate primary diagnosis would be cervical spondylosis with myelopathy with spinal stenosis being secondary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient care provided from July 8, 2020, to July 12, 2020.
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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary immediate denture (D5130), complete maxillary overdenture (D5863), surgical placements of implant bodies: endosteal implants (D6010), and prefabricated abutments (D6056).
You asked the Plan to pre-approve the maxillary immediate denture, complete maxillary overdenture, endosteal implants, and prefabricated abutments. You say that it is better for you to have the implants so you can chew because of your health issues. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve a maxillary immediate denture (D5130), complete maxillary overdenture (D5863), surgical placements of implant bodies: endosteal implants (D6010), and prefabricated abutments (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia services (D9222 and D9223).
You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that you are having a wisdom tooth removed and do not want to be awake for the procedure. You also say that you are in pain. The Plan denied your request. The Plan says these services 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep sedation/general anesthesia services (D9222 and D9223).