Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of impacted tooth, soft tissue, (D7220) for teeth # 1 and 16.  You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain around your whole jawline. You say that your sinuses keep swelling. You say that all of your teeth have significant cavities and are not restorable according to the surgeon. You also say that it is better to remove them all at one time and would be more cost effective. The Plan denied your request. The Plan says the requested extractions for impacted teeth are not necessary. The Plan also says that lesser codes may be requested.  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 dental services 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 dental services. Our reviewer says that the requested removal of impacted tooth, soft tissue, for teeth # 1 and 16 do not meet criteria. Our physician reviewer found neither teeth # 1 or # 16 appear to be impacted in the soft tissue. The procedure code D7220 is reserved for teeth that are covered by the soft tissues and not erupted. The reviewer found that tooth # 16 would require bone removal to be able to extract the tooth. The reviewer found that tooth # 1 may be able to be removed without the cutting of bone. Therefore, the reviewer found that the current codes provided do not meet the Plan criteria for the involved teeth.  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 dental services have not been met. Specifically, the file shows that teeth # 1 and 16 are not impacted in soft tissue. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth, soft tissue, (D7220) for teeth # 1 and 16.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on September 2, 2021.  

You asked the Plan to pay for a comprehensive oral evaluation. You say that you want the Plan to cover this service because you had to see a new provider. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 36 months.  

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.      

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 2, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on September 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ropinirole ER for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Ropinirole ER 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pods for an Omnipod insulin delivery system (A9274).  You asked the Plan to pre-approve the pods. You say that these are medically necessary for you. The Plan denied your request. The Plan says that your request is not a covered benefit because it does not meet Medicare's definition of durable medical equipment.  The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, such as the Omnipod, are not covered by Medicare Part B as they do not meet the definition of durable medical equipment.  Although this may be appropriate for you, neither Medicare nor the Plan covers this device or supplies. Therefore, we decided that the Plan does not have to pre-approve pods for an Omnipod insulin delivery system (A9274).   Benefits for the pods 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on June 10, 2020.  You asked the Plan to pay for the therapeutic activities services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.   We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that the services were performed by an occupational therapist in a home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on June 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428) provided on August 16, 2021.  You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says the copayment was applied correctly.  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 $250 copayment for ambulance services.      You have been asked to pay a $221.98 copayment for non-emergency ambulance transportation. The services at issue fall within the ambulance services benefit category. Since the Allowed Amount for this service is less than the required copayment of $250, you have been asked to pay only $221.98. 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 waive the copayment for non-emergency ambulance transportation (A0428) provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lower limb prosthesis (L5301).  You asked the Plan to pre-approve the lower limb prosthesis. You say that the prosthesis is medically necessary. The Plan denied your request. The Plan says the requested device exceeds the enrollee's functional abilities.  The Plan follows Medicare rules. Medicare rules say that determination of the medical necessity for certain components/additions to a prosthesis is based on the beneficiary's potential functional abilities.  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 lower limb prosthesis. Our reviewer says that the requested prosthetic is not medically necessary. Our physician reviewer found the patient has had a functional decline and it is not clear that he is ready to ambulate with the requested prosthetic device. The patient is still working with therapy.   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 lower limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis (L5301).
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 the stay is medically necessary. The Plan denied your request. The Plan says your records show your underlying medical conditions are stable, do not require close medical supervision or titration of the medications you normally take by mouth, and do not require that you be seen by a rehabilitation doctor at least three (3) times a week. The Plan states you clearly require physical and occupational therapy as well as pain control with medicine by mouth and routine wound care. The Plan states you do not have complex rehabilitation needs that can only be met at an IRF. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical removal of bladder and prostate for bladder cancer. Complications included gastrointestinal bleeding, atrial fibrillation, and lower extremity blood clot leading to an above the knee amputation. 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 patient 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 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 long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided the enrollee appears to be unstable for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for podiatry services received on August 12, 2021.  You asked the Plan to pay for the services. You say that you are in an assisted living facility and the service was set up by the activity's director. The Plan denied your request. The Plan says the services were not urgent, emergent, or pre-authorized.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal.   The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for podiatry services received on August 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the PBRT (CPT code 77523), for the enrollee.  You asked the Plan to pre-approve the PBRT. You say that the enrollee has Stage I or II non-small cell lung cancer of right upper lobe and per provider proton therapy is medically appropriate and necessary for the enrollee. The Plan denied your request. The Plan says in order for the requested service to be covered, the enrollee would need to have: Records that show that they are in a registered clinical trial. The Plan states the enrollee's records do not show that they are in a clinical study.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PBRT have not been met. The enrollee's records do not show that they are in a clinical study. The rules say that this section defines conditions that are still under investigation and would be covered when part of a clinical trial, registry or both. Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers. Therefore, we decided that the Plan does not have to pre-approve the PBRT (CPT code 77523), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sixteen additional physical therapy (PT) visits (97110).  You asked the Plan to pre-approve additional PT visits. You say that additional therapy is necessary to strengthen your muscles and improve your back and neck pain. The Plan denied your request. The Plan says the requested physical therapy is not medically necessary in this case. Your physical therapy assessments did not show any functional improvement. At this time, it is expected that you can continue with your home exercise program to maintain and/or maximize any benefits you may have achieved as a result of physical therapy.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the medical records provided, there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment and that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgement of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. Given the limited records provided with regard to your treatment and progress thus far, there is inadequate documentation to certify that further physical therapy treatment meets Medicare criteria for medical necessity.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve sixteen additional physical therapy (PT) visits (97110).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a prostate rectal spacer (55874).  You asked the Plan to pre-approve a prostate rectal spacer. You say that you believe this service is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied.  The Plan must follow Medicare rules. Medicare rules say that a prostate rectal spacer will not be covered if the prostate volume is greater than 80 cc.  We looked at the file and Medicare rules. In this case, the medical documentation clarifies that the prostate volume of the enrollee is 150 cc. This is greater than the limit of 80 cc as cited by the LCD. Based on this information, we decided that Medicare rules for coverage of a prostate rectal spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate rectal spacer (55874).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring in the operating room (95940) provided on June 14, 2021.  You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that these ancillary services are not affiliated with the hospital facility and should be paid separately. The Plan denied your request. The Plan says that the provider type submitted on this claim is not found on the Medicare Provider/Supplier to Healthcare Provider Taxonomy Crosswalk, and therefore is not eligible to receive Medicare payment. The provider in question is not a recognized facility or legally qualified physician, and billing agents and third-party vendors do not fall within the category of eligible providers, these services are not payable under the Plan.    In addition, records indicate that these services were provided for another physician and/or facility, and not at the request of the enrollee. It is suggested that you contact the physician and/or facility for any reimbursement. This claim has been paid under a separate claim as submitted by the facility/hospital provider as part of the Inpatient Prospective Payment System (PPS).  The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS. Medicare rules also say that no Medicare payment can be made to a provider that is not enrolled in the Medicare program.  We looked at the file and Medicare rules. The provider in this case is not eligible to enroll in the Medicare program and bill directly. In addition, the services at issue were performed during an inpatient spinal surgery. Medicare pays for inpatient services through the prospective payment system (PPS) using Diagnosis Related Groups (DRGs). The payment to the facility is for all items and non-physician services rendered to an inpatient during their stay. Since these services are items/non-physician services, payment for them is made to the facility. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring in the operating room (95940) provided on June 14, 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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be met in 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.   Our physician reviewer found that 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. 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 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.