Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 enrollee requires an interdisciplinary team approach, and her needs cannot be met at a lesser level of care. The Plan denied your request. The Plan says the member's needs can be safely met in a less intensive setting.
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 was admitted for bacteremia, sepsis and an infected pacemaker lead. Medical problems are stable and there are no complex nursing or rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 6, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain 
documentation requirements must be met. 
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record 
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay 
for the injection rendered on September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on May 20, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99291 is not supported.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care time. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hyaluronic acid injections.  You asked the Plan to pre-approve hyaluronic acid injections. You say that these injection services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested injection service is only covered when performed on a weight-bearing joint.  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 hyaluronic acid injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 52-year-old female with a history of right shoulder pain for several months described as a 10/10, which worsens with movement and palpation. Her provider has requested a hyaluronic acid injection / arthrocentesis with ultrasound guidance. Hyaluronic acid injections are only approved for knee osteoarthritis. Requests for hyaluronic acid injections to other joints are considered experimental. The review has determined that the items/services at issue in this case are 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 hyaluronic acid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve hyaluronic acid injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional home health physical therapy sessions.
You asked the Plan to pre-approve the additional home health physical therapy sessions. You say that additional visits are medically necessary. The Plan denied your request. The Plan says it has already approved 11 home physical therapy visits to teach you a home exercise program. Continuing this program should help you maintain your level of function or allow you to improve further. The Plan says that the medical records do not support the need for more skilled therapy at home at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health physical therapy sessions. Our reviewer says that you do not meet criteria for continued home health physical therapy services. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in safety, proper posture, transfer training, strengthening and ROM exercises and posture training exercises. The requested services are not part of a maintenance program, and do not require the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the your current condition or to prevent or slow further deterioration. 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 additional home health physical therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional home health physical therapy sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MyoPro 2 Motion G.  You asked the Plan to pre-approve MyoPro 2 Motion G. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is not a covered benefit.  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 MyoPro 2 Motion G. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro 2 Motion G have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 Motion G.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan drops for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Zioptan drops for the enrollee.
Benefits for this drug 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MRI, brain (including brain stem); without contrast material (CPT code 70551).  

You asked the Plan to pre-approve the MRI. You say that you are feeling dizzy when you are awake, your memory is getting worse, and is getting harder to focus. The Plan denied your request. The Plan says the clinical notes do not have an active order or address an MRI of the brain. The Plan states the clinical notes do not have focal neurologic findings, or any new onset of headaches or pain. The Plan states the clinical notes also indicate an unresponsiveness to antibiotic treatment and symptomatic treatment.  

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 physical findings reveal no focal neurologic abnormalities. There was no x-ray of the brain or computed tomography (CT). The records did not clearly rule out metabolic or cardiac cause of symptoms via examination or blood work to justify advanced imaging, and there was no clear evidence of a red flag diagnosis. Therefore, this request for MRI will be considered 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI, brain (including brain stem); without contrast material (CPT code 70551).
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve the custom fabricated abutment (D6057) and implant supported crown (D6065) for tooth #7 and #10.  You asked the Plan to pre-approve the custom fabricated abutments (D6057) and implant supported crowns (D6065). You say that the implants were recommended because the patient will need treatment once the bridge is sectioned. The Plan denied your request. The Plan says that the x-rays do not show that an implant is necessary.  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 custom fabricated abutments (D6057) and implant supported crowns (D6065) 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 pre-approve the custom fabricated abutments (D6057) and implant supported crowns (D6065). Our reviewer says that the abutment and crown portions are necessary and part of the overall procedure. Our physician reviewer found that there must be placement of the implant body(D0610), abutment (D0657), and a crown (D6065) to complete the implant procedure to functionality. The implant bodies were already approved for placement. Since, the abutment is necessary to interface with the endosseous implant body, the crown is necessary to restore the replacement tooth to function.  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 custom fabricated abutments (D6057) and implant supported crowns (D6065) have been met. Therefore, we decided that the Plan has to pre-approve the custom fabricated abutment (D6057) and implant supported crown (D6065) for tooth #7 and #10.     If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 27, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the service billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to verify if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. You say that the enrollee needs adequate care while still in a cast. The Plan denied your request. The Plan says the enrollee's care appears to be custodial.  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. Continued SNF services beyond February 21, 2022, were requested. 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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, was treated for pain, and her lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at a minimal assist level with functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5050) purchased on September 10, 2021.  You asked the Plan to pay for the hearing aids. You say that you saw another provider first but were able to purchase these hearing aids for a lower cost from this provider. You say you could not ask for approval for these services. The Plan denied your request. The Plan says this provider is out-of-network, and out-of-network hearing aids require prior authorization. Prior authorization was not requested or obtained in this case, and these services could have been received from an in-network provider.    Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan requires that prior authorization be submitted and approved before hearing aids and routine hearing services are received out-of-network.   We looked at the file and the Plan's rules. The provider in this case is out-of-network, and the Plan had in-network providers available who could have provided the necessary services. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5050) purchased on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on September 9, 2021.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that the frequency limitation was not exceeded. You also say that it appears there is some confusion, and you would like this claim to be paid. The Plan denied your request. The Plan says your intraoral x-rays benefit has been satisfied and the frequency limitation has been exceeded.

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, intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on September 9, 2021 which was covered at the OON rate by the Plan and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less (CPT code 14040) provided to the enrollee on July 15, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.
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 asked our coder 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 service. Our reviewer found the record indicates that the enrollee underwent an operative procedure involving the eye. The elements of the coverage criteria are not satisfied. The requested service is not supported.
We looked at this coder'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 pay for the adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less (CPT code 14040) provided to the enrollee on July 15, 2021.