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

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD, or the MILD procedure).
You asked the Plan to pre-approve MILD procedure. You say that this procedure is covered by Medicare and is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because physical examination and computed tomography (CT) scan results do not indicate the necessity of surgery.
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 MILD procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of lumbar spinal stenosis with neurogenic claudication. The enrollee reported lower back pain of an aching, itching quality. The duration of pain was "none."
There were no associated symptoms. On July 13, 2021, the enrollee's pain was reported as 0 out of 10 with no
associated symptoms. Based on the most recent available clinical documentation, the requested procedure is
not medically necessary for the enrollee 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 MILD procedure have not been met. Therefore, we decided that the Plan does
not have to pre-approve percutaneous image-guided lumbar decompression (PILD, or the MILD procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-network.

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 services at issue in this appeal. 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 services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay a 50% coinsurance for a crown (D2750 and D2751) provided by a participating provider.
You asked the Plan to pay a 50% coinsurance for a crown. You say that the rules say that the Plan will pay 50% of the cost of the crowns. The Plan denied your request. The Plan says a 50% coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for optional supplemental benefit/class 3 major services. You have been asked to pay a 50% coinsurance of the allowed amount for a crown. The total allowed amount is $993. The amount you are being asked to pay is $496.50 ($993 x 50% = $496.50). A crown falls within the optional supplemental benefit/class 3 major services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay a 50% coinsurance for a crown (D2750 and D2751) provided by a participating provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency, routine
transportation trips.
You asked the Plan to provide coverage for additional non-emergency, routine transportation trips. The Plan
denied your request. The Plan says the evidence shows the enrollee has used thirty-two (32) one-way trips
covered by his health Plan for the year 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 32 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide coverage for additional non-emergency, routine transportation
trips
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan (93970) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the duplex scan. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 services at issue in this appeal. 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 a duplex scan (93970) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal crown (D6060).

You asked the Plan to pre-approve the endosteal implant, prefabricated abutment, and abutment supported porcelain fused to metal crown. The Plan denied your request. The Plan says these services are not covered under your benefit 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 surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal crown (D6060).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate a history of chronic low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. This is not being requested for chronic low back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient procedure: neurostimulator implant (DyAnsys).

You asked the Plan to pre-approve neurostimulator implant. You say that it was determined by the provider that the enrollee would be an excellent candidate for the PENS (percutaneous electrical nerve stimulation) unit to help with chronic pain and reduce the use of narcotics. The Plan denied your request. The Plan says any ear or auricular electrical devices are non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neurostimulator implant have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient procedure: neurostimulator implant (DyAnsys).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like to be admitted to inpatient
rehabilitation for continued therapy as she would like to return to her prior level of function. The Plan denied
your request. The Plan says not medically necessary under Medicare guidelines.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two provisional crowns (D2799 x2).
You asked the Plan to pre-approve the provisional crowns. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 two provisional crowns (D2799 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rigid side rails for a wheelchair (K0108).

You asked the Plan to pre-approve the rigid side rails.. You say that this accessory is medically necessary. The Plan denied your request. The Plan says these side rails are used for operating the wheelchair on uneven terrain that would only be found outside the home, and therefore, are non-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 rigid side rails for a wheelchair (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transfer bench (CPT code 99070), for the enrollee.
You asked the Plan to pre-approve the transfer bench. You say that this is medically necessary as the enrollee is dependent on equipment for bathing. The Plan denied your request. The Plan says it is considered to be a comfort/convenience item and not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the transfer bench (CPT code 99070), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at-home visual field assessment testing (Foresee Home
visual field home kit) to be provided by an out-of-network provider.
You asked the Plan to pre-approve visual field assessment testing. You say that this testing has been covered by
Medicare since 2015 and is medically necessary. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because continuous daily screening with the use of Foresee Home is
considered a screening tool and is performed at a frequency greater than is necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, visual field assessment testing, is being requested for daily home-based
monitoring of the enrollee, which is considered a screening purpose. Medicare does not cover this test for
screening purposes. Therefore, we decided that the Plan does not have to pre-approve at-home visual field
assessment testing (Foresee Home visual field home kit) to be provided by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermal-fat-fascia graft (CPT code 15770), 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 the clinical value and effectiveness of dermal-fat-fascia graft in the setting
of laminectomy have not been demonstrated in the peer-reviewed literature.
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 dermal-fat-fascia graft for use in laminectomy surgery is experimental. More research is
needed.
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 dermal-fat-fascia graft (CPT code 15770), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface, (E0466).
You asked the Plan to pre-approve a ventilator. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says Medicare guidance says ventilators used to provide CPAP or bi-level CPAP therapy will be denied as not reasonable and 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 a ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease.
A ventilator is not eligible for reimbursement for any of the conditions described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary. The requested device would be used in a BiPAP mode that could be provided with a BiPAP (E0471) device with AVAPS added to assure adequate tidal volumes. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface, (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the urology office visit to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the urology office visit. You say that you have seen multiple doctors and
they have not helped solve your urination issue. The Plan denied your request. The Plan says the provider is
out-of-network.
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. The records provided for review do not show that the service at
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the urology
office visit to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom made compression stockings.
You asked the Plan to pre-approve the custom compression stockings. You say that these stockings are
medically necessary. The Plan denied your request. The Plan says the requested stockings are not covered
under Medicare rules.
The Plan must follow Medicare rules. The rules say that these stockings are noncovered because they do not
meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve custom made
compression stockings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
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 the SNF admission. You say that you feel that you need care in the SNF
setting due to your condition. The Plan denied your request. The Plan says you have no need for skilled care on
a daily basis.
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 admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee
appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance
program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter,
can be provided 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 the SNF admission 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is going to be discharged from the hospital soon, and requires ongoing medical care. Other facilities cannot meet the enrollee's care needs. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The services the enrollee requires can be provided in an alternate setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have any PEG needs and no complex medical needs. There are no daily wound care needs and no intravenous medications. Transfer to an LTACH will not provide any additional services or change the short or long-term outcome. There is no medical necessity for an LTACH; the enrollee can safely be managed in an alternate 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services