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

 We decided that the Plan does not have to pre-approve Rituximab injection services.  

You asked the Plan to pre-approve Rituximab injection services. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the drug being requested is not indicated for the enrollee's condition and is not considered medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Rituximab injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there have been desensitization protocols involving a number of pharmaceuticals in recent years. However, the use of Rituximab remains investigational and unapproved for this indication, according to guidelines. It is premature to presume clinical outcomes and benefit. At the current time, Rituximab is not medically necessary for the enrollee's condition.    

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an apicoectomy (D3421).  You asked the Plan to pre-approve the apicoectomy. You say that you need to get your tooth pulled but you need to be put to sleep for the procedure. You also say that your tooth needs to be extracted so the infection does not get into your heart valve. The Plan denied your request. The Plan says this service is 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 an apicoectomy (D3421).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiofrequency ablation services provided on September 23, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is investigational.  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 pay for the services provided. Our physician reviewer found that the enrollee has a history of low back pain without radicular pain. According to the literature, sacral lateral nerve branch blocks, ablations, and neurotomies for the diagnosis and treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of sacroiliac joint pain. Therefore, the services are 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation services provided on September 23, 2021.
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 was completely independent before. You say that the enrollee does not currently have a care giver. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan says that the enrollee's rehabilitation needs do not require an intensive team approach and can be met at 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lower extremity infection and had below the knee amputation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on February 23, 2021.  You asked the Plan to pay for the CT interpretation. You say that this should be paid as multiple exams were performed on this date of service. The Plan denied your request. The Plan says the code was not billed with an NCCI modifier as required.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496, which was billed on another claim for this same provider.   This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a manual wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says that there are in network providers available to provide the wheelchair.  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 manual wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve cardiology services. You say that your previous doctor left, and you cannot find another specialist that is accepting new patients in-network. The Plan denied your request. The Plan says an in-network provider was given to the enrollee that is accepting new patients.  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 cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that your ability to regain maximum functions is seriously jeopardized and you do not feel safe due to you being at a facility for less than forty-eight (48) hours and had to be admitted back to the hospital for not being able to breathe. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility.  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. You were admitted for shortness of breath after recent Coronavirus (COVID-19) infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient mental health care.  You asked the Plan to pre-approve inpatient mental health care. You say that you are not safe to be discharged from home at this time. You state the doctors do not feel that it is safe yet to discharge you to a lower level of care. The Plan denied your request. The Plan says you are not having plan or intent to harm yourself or others, you are not hearing voices, telling you to harm yourself or anyone else, you are not aggressive or violent. No medical issues that require treatment at this level of care, no severe side effects from medications, and you can be treated at a lower level of care. The Plan states if you have not yet been discharged from the hospital, then the Plan may be able to approve intensive outpatient with or without therapy.  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 mental health care. Our physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 17, 2022, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation but slight auditory or visual hallucinations "almost gone", delusions and was not showing any behaviors or aggression 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 inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the total knee arthroplasty (27447) rendered by the out-of-network (OON) provider on September 16, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the total knee arthroplasty (27447) rendered by the out-of-network (OON) provider on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided the Plan does not have to pre-approve compression stockings coded as A6549 and A6530.  You asked the Plan to pre-approve these compression stockings. You say that the requested compression stockings are medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 and A6530 are noncovered. Although these items may be appropriate for your use, they are not paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with codes A6549 and A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on October 27, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that this is the first time seeing this provider. The dentist you were using prior is no longer in-network with your Plan. You also say that you believe this should be covered. The Plan denied your request. The Plan says the services rendered exceeded the frequency limitation under your dental Plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a comprehensive oral evaluation once every 36 months.    We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation on September 11, 2020, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Arthroscopy services (29825 and 29826) provided on July 27, 2021.  You asked the Plan to pay for codes 29825 and 29826. You say that the medical records support the billing of codes 29825 and 29826 provided on July 27, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 29825 and 29826 provided on July 27, 2021.  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 29826 is Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).  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 code 29826. Our reviewer says that the medical records do not support the billing of code 29826 provided on July 27, 2021. Our reviewer found the operative report does not support a decompression of subacromial space with partial acromioplasty was performed.  To cite the operative report "Attention was then turned to the subacromial space.  Because of significant bursitis, we elected to proceed with soft tissue subacromial decompression and bursectomy.  Soft tissue from under surface of acromion was removed.  The thickened coracoacromial ligament was recessed along the under surface of the acromion with an ArthroCareWand".   Operative report does not describe a partial acromioplasty was performed, and therefore this procedure cannot be verified.  Furthermore, we have confirmed that code 29825 is a column II code to column I code 29827. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 29825 and 29826 have not been met. Therefore, we decided that the Plan does not have to pay for the Arthroscopy services (29825 and 29826) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the non-therapeutic continuous glucose monitor (CGM) sensors (A9276).  You asked the Plan to pre-approve the non-therapeutic CGM sensors. You say that you need this item. The Plan denied your request. The Plan says Medicare only covers therapeutic continuous glucose monitoring systems with an FDA approved non adjunctive indication and a Guardian Continuous Glucose Monitor is considered by Medicare to be a non-therapeutic Continuous Glucose Monitor.  The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-therapeutic CGM sensors have not been met. Specifically, the requested CGM device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the non-therapeutic continuous glucose monitor (CGM) sensors (A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the comprehensive oral exam. You say that the exam was done to prioritize your treatment for this year and the following year. The Plan denied your request. The Plan says this claim has been processed and paid correctly according to your OON benefits.  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 comprehensive oral exam up to the Plan's allowance when provided OON. You are responsible for balances up to the dentist's charge.  We looked at the file and Medicare rules. The Plan provided documentation showing that they covered the full allowed amount for this service. Since the exam was provided OON you are responsible for the difference between the allowed amount and the total cost billed by the OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging (D0230) provided by a participating provider on September 27, 2021, to October 18, 2021.  You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental services are covered dental benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging (D0230) provided by a participating provider on September 27, 2021, to October 18, 2021.