Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic radiofrequency ablation (RFA).
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have mid- and low-back pain. RFA is requested for back that does not radiate to other areas of the body. You have well-documented thoracic facet joint pain as the origin of the pain, as evidenced by successful response to two separate sets of thoracic medial branch block injections. You have had two RFA procedures in the past year on October 13, 2020 and September 21, 2020. Further RFA is not medically necessary, as you have already had two sessions in 12 months.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve thoracic radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant procedure provided on April 14, 2021.
You asked the Plan to pay for the implant procedure. You say that prior to enrolling in this plan you inquired about copayments and you were advised you would be covered. You also say that you are not satisfied that the dental office charged you extra. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant procedure provided on April 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on October 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 wound care at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the debridement services provided on October 27, 2020 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure monitor.
You asked the Plan to pre-approve the requested item. You say that monitoring your blood pressure is essential. The Plan denied your request. The Plan says the item is not covered by Medicare or your plan.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home hemodialysis technician.

You asked the Plan to pre-approve the home hemodialysis technician. You say that the enrollee needs to have a hemodialysis home technician to help because their current caregiver who is trained to do home hemodialysis at home can no longer help. The Plan denied your request. The Plan says the enrollee has a caregiver who is trained to do hemodialysis at home.

The Plan must follow Medicare rules. Medicare rules say that staff-assisted home dialysis using nurses to assist ESRD beneficiaries is not included in the ESRD Prospective Payment System and is not a Medicare covered service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home hemodialysis technician have not been met. Therefore, we decided that the Plan does not have to pre-approve a home hemodialysis technician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered from February 27, 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 critical care time spent on the enrollee. 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 from February 27, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Conformis Knee Replacement to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the Conformis Knee Replacement. You say that you would like reconsideration because you traveled to receive the approved, pre-operative computed tomography (CT) scan and were under the impression that this surgery would be approved. The Plan denied your request. The Plan says that this surgery can be obtained 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. 

We looked at your request, the file and Medicare rules. There is no indication that this specific procedure may be rendered by the Plan's recommended network providers. The providers suggested by the Plan are not listed as surgeons who provide knee replacements with Conformis. Of note, the Plan approved the CT Scan with the requested out-of-network provider, which further suggests this service is not available in-network. Based on this information, we have determined that criteria for coverage of this out-of-network service have been met. Therefore, we decided that the Plan has to pre-approve the Conformis Knee Replacement to be provided by an out-of-network (OON) provider.

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 pre-approve an office visit consultation for a second opinion to be
provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit consultation for a second opinion. You say that this care from
an OON provider is medically necessary. The Plan denied your request. The Plan says they have multiple in-network
providers available to treat the enrollee's condition.

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
an office visit consultation for a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the sinus x-ray rendered on June 14, 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 claim was billed without a valid diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary diagnosis code. 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 sinus x-ray rendered on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and
supplies.

You asked the Plan to pre-approve the therapeutic continuous glucose monitor and supplies. You say that this
device is medically necessary for handling the enrollee's diabetes. The Plan denied your request. The Plan says
the criteria for coverage have not been met for the requested continuous glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the
Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet light therapy.
You asked the Plan to pre-approve ultraviolet light therapy. You say that it is discrimination that the requested service is covered for psoriasis but not your skin condition. The Plan denied your request. The Plan says rules for coverage for ultraviolet cabinets have not been met.
The Plan must follow Medicare rules. Medicare rules say that ultraviolet cabinets are covered for selected patients with generalized intractable psoriasis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultraviolet light therapy have not been met. Specifically, the request is for an ultraviolet cabinet and you do not have a diagnosis of psoriasis. There is no provision for an exception to the Medicare rule. Therefore, we decided that the Plan does not have to pre-approve ultraviolet light therapy
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neuropsychological testing.

You asked the Plan to pre-approve Neuropsychological testing represented by codes 96116, 96121, 96132, 96133, 96136, 96137, 96138. You say that you have concerns about your memory. The Plan denied your request. The Plan says there was no psychiatric diagnostic interview or screening to assess cognitive function for the need for testing.

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. The diagnosis codes are Other Amnesia and Dizziness and Giddiness. The record does not show suspected mental illness or disability therefore the testing would be screening and not covered. Based on this information, we decided that Medicare rules for coverage of Neuropsychological testing represented by codes 96116, 96121, 96132, 96133, 96136, 96137, 96138 have not been met. Therefore, we decided that the Plan does not have to pre-approve Neuropsychological testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95886) provided on February 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on code was not billed with an appropriate primary code.
The Plan must follow Medicare rules. Medicare rules say that an add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. We looked at the file and Medicare rules. Code 95886 is an add-on code. In this case, code 95886 was not billed with an appropriate primary code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95886) provided on February 4, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Orchiectomy for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that that criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. Orchiectomy is
considered medically reasonable and necessary as a last resort treatment for orchialgia that has failed
conservative treatments. The medical records indicate that the enrollee has failed conservative treatments and
orchiectomy is necessary. Our physician reviewer found that the enrollee's condition meets criteria for coverage
of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove
Orchiectomy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two core buildups, including any pins when required
(D2950 x2), or pay more for the periodic oral evaluation (D0120), prophylaxis (D1110), and two crowns
(D2740 x2) provided on March 17, 2021, and April 19, 2021, by an OON provider.
You asked the Plan to pay for the core buildups, and to pay more for the periodic oral evaluation, prophylaxis,
and crowns. You say that you would like to know if you can be reimbursed for these services because you paid
for them in full. The Plan denied your request. The Plan says core buildup is not a covered service. The Plan
also says that these services were performed by a non-participating provider, and you are responsible for the
coinsurance plus any difference between the Maximum Allowable Fee and the amount the provider bills you
for the services.
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, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. You are responsible for a 50% coinsurance for
each periodic oral evaluation (D0120) and prophylaxis (D1110) that is received OON, and you are responsible
for a 75% coinsurance for each crown (D2740) that is received OON. You are also responsible for the
difference between the billed amount and allowed amount for services that are received OON. Therefore, we
decided that the Plan does not have to pay for the two core buildups, including any pins when required (D2950
x2), or pay more for the periodic oral evaluation (D0120), prophylaxis (D1110), and two crowns (D2740 x2)
provided on March 17, 2021, and April 19, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) and cervical collar (L0174), provided on October 8, 2020.
You asked the Plan to pay for a back brace and cervical collar. You say that the item is medically necessary. The Plan denied your request. The Plan says there was no delivery confirmation document or documentation in the exam notes validating the member received the device or supplies.
The Plan follows Medicare rules. Medicare rules say that spinal orthosis are covered under certain circumstances listed in the Medicare Rules section of this letter. 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 a back brace and cervical collar. Our
reviewer says that the item is not medically necessary. Our physician reviewer found there is no specific documentation indicating medical necessity for the requested items and there is no evidence by physical exam of any cervical or spinal instability. 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 back brace and cervical collar have not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) and cervical collar (L0174), provided on October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care 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 the patient was admitted for pneumonia, bacteremia and end stage renal disease.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 this patient 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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for bacteremia and lower extremity weakness. Your 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 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.