Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osteogenesis stimulator, electrical, non-invasive, other than spinal applications (E0747).
You asked the Plan to pre-approve Osteogenesis stimulator. You say that you are submitting additional information and request an appeal on the basis of meeting criteria for the use of electrical bone growth stimulation for treatment of a nonunion fracture of the long bone. The Plan denied your request. The Plan says the Medicare criteria has not been met for the requested Osteogenesis stimulator.
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 Osteogenesis stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that meets the requirements listed in the Local Coverage Determination for Medicare coverage for the requested osteogenesis stimulator. The provided radiologic reports do not demonstrate evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator. A radiologic study from 08/25/2021 is reported to show evidence of healing and callus formation on the lateral view. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve Osteogenesis stimulator, electrical, non-invasive, other than spinal applications (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment-supported porcelain/ceramic crown (D6058) and a custom abutment (D6057).

You asked the Plan to pre-approve the dental services. You say that you had the approved implants placed in your mouth and you need the crowns for medical necessity. The Plan denied your request. The Plan says this request exceeds the limit of two crowns per calendar year.

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, which has a limit of two crowns per calendar year. 

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, as the enrollee received similar services on both April 21, 2021 and May 24, 2021. Therefore, we decided that the Plan does not have to pre-approve an abutment-supported porcelain/ceramic crown (D6058) and a custom abutment (D6057).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on February 3, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not
been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eligard 45 mg injection.
You asked the Plan to pre-approve Eligard. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eligard 45 mg injection.
Benefits for Eligard may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 need admission to acute inpatient rehabilitation
due to severity of symptoms. The Plan denied your request. The Plan says criteria for admission to the IRF
setting have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
rehabilitation program. There is not a reasonable expectation that you will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: 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 are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to
expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313) and
electronic connection between wheelchair controller and two or more power seating system motors, including
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
(CPT code E2311), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee's mobility is limited due to a
neurological condition, myopathy, or congenital skeletal deformity, and the enrollee meets coverage criteria for
a power tilt and power recline seating system. The Plan denied your request. The Plan says the DME is not
necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable
controller, harness and electronic connector to 2 power options) are not medically necessary. They are
necessary when there is a medical need to control power options though the joystick. The notes do not show a
medical need to control the power options through the joystick. The power options can be controlled using their
own switches. These switches can be made any size without asking for a separate request. They can be made
from any material without asking for a separate request. All of this can be done without the need to use the
joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial
issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and
mounting hardware (CPT code E2313) and electronic connection between wheelchair controller and two or
more power seating system motors, including all related electronics, indicator feature, mechanical function
selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PENS unit (CPT code(s): L8679 and 64555).
You asked the Plan to pre-approve the DME. You say that you would be an excellent candidate for the PENS
unit to help with chronic pain and reduce the use of narcotics. You state that you are likely to obtain significant
therapeutic benefit from the neurostimulator treatment. The Plan denied your request. The Plan says this is not
covered by Medicare.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. Any ear or auricular electrical devices
(e.g., DyAnsys) are also non-covered by Medicare as electrical acupuncture. Therefore, we decided that the
Plan does not have to pre-approve PENS unit (CPT code(s): L8679 and 64555).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain (70450).
You asked the Plan to pre-approve a CT scan of the head or brain. You say that this imaging service 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 CT scans 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 a CT scan of the head or brain. Our reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found that the patient is a 45-year-old female with dizziness and imbalance. Orthostatic dizziness was suspected according to the notes. Based on the provided documentation, no brain imaging is warranted as there were no clear signs or symptoms to support this test. Other more likely causes of her symptoms should be worked up such as changes in medications which was concurrently planned. Therefore, without sufficient support made for this request, the CT brain without contrast 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 a CT scan of the head or brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain (70450).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because you do not have the proper assistance at home for physical therapy. The Plan denied your request. The Plan says the records do not show that daily skilled services can be provided only on an inpatient basis in a SNF.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, cervical spine; without contrast material (CPT code 72125), for the enrollee.

You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says the CT scan is not necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer found no planned treatment was documented based on the results of this proposed imaging. It was not clear how it would lead to improvement in care and outcome to complete this test. Therefore, based on the provided documentation, the CT 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, cervical spine; without contrast material (CPT code 72125), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for an office visit
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available to render medical care and services.
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 a referral out-of-network for an office visit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine supplies, provided on February 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the CPAP machine supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 

We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine supplies, provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says dentures that are stolen, lost, or damaged are not able to be replaced.

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 dentures once every five years. 

Lower dentures and upper dentures were last received less than five years ago on December 3, 2021 and May 12, 2021, respectively. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PENS unit (CPT code(s): L8679 and 64555).

You asked the Plan to pre-approve the DME. You say that you are recommending the neurostimulator to
decrease pain. The Plan denied your request. The Plan says you are recommending the neurostimulator to
decrease pain.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The rules say that Medicare does not
cover nerve stimulation behind the ear to treat back pain. Therefore, we decided that the Plan does not have to
pre-approve PENS unit (CPT code(s): L8679 and 64555).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management coded 99239 provided on August 27, 2020.
You asked the Plan to pay for the hospital discharge day management. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met.
Therefore, we decided that the Plan does not have to pay for the hospital discharge day management coded 99239 provided on August 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 24, 2021.
You asked the Plan to pay for physician's services. 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
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on March 1, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 24, 2021.