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

 
We decided that the Plan does not have to pre-approve arthrodesis, open, SI joint, including obtaining bone 
graft, including instrumentation, when performed (CPT code 27280). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the records from your provider do not show, indicate or support the medical necessity 
for the requested surgical procedure. The Plan states there is no indication of three (3) failed responses to 
alternative treatments, exams to show the etiology of your pain related to your SI joint, and there is a diagnosis 
of spine degeneration. 
 
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 criteria for SI joint fusion not met. There is no clear clinical evidence that the SI joint is the 
pain generator. There is also lumbar spine degeneration. 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 arthrodesis, open, SI joint, including obtaining bone graft, including instrumentation, when 
performed (CPT code 27280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) for teeth # 4, 7, and 13.
You asked the Plan to pre-approve the dental services. You say that your teeth are starting to change color and rot. You say that the plan will cover the extractions. You say that the plan does not want to pay to replace the bone. You also say that you are not sure about the implants. The Plan denied your request. The Plan says osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla is not listed as a covered service.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) for teeth # 4, 7, and 13.
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 full
recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee can safely receive the services they need in an alternate 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 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.
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 needs admission to an acute inpatient rehabilitation facility. The Plan denied your request. The Plan says a transfer to an acute inpatient rehabilitation facility is not medically necessary.
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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that your doctor told you that this injection will work for your pain. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Orthovisc. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found you have right knee pain. The documentation does not support that you have tried and failed Durolane, Euflexxa, Gelsyn-3, or Supartz. In addition, the clinical notes do not support radiographic evidence of osteoarthritis. Therefore, you do not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair
You asked the Plan to pre-approve the reclining chair. You say that you require a recliner to elevate your legs.
The Plan denied your request. The Plan says a reclining chair does not primarily serve a medical purpose.
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 a recliner chair
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency non-ambulance transportation services in excess of fifty-two trips.
You asked the Plan to pre-approve the additional non-emergency non-ambulance transportation services. You say that you require additional transportation for medical appointments. The Plan denied your request. The Plan says you were enrolled with this plan from January 1, 2021, to January 31, 2021, then from March 1, 2021, to June 30, 2021, and have finally resumed coverage with this Plan starting September 1, 2021. The Plan also says that re-enrollment with the Plan will not trigger a reset in the balance of trips available, and the previous balance of used trips will carry forward for the rest of the calendar year.
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 fifty-two (52) 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. Trips in addition to the fifty-two (52) one-way trips are not covered. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency non-ambulance transportation services in excess of fifty-two trips.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 there is no need for physician supervision 3 times per week (at a minimum) for
the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no
documented skilled nursing needs. While the enrollee may benefit from physical therapy and occupational
therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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 IRF care 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 provided 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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower leg platform crutch (E0118).
You asked the Plan to pre-approve a lower leg platform crutch (E0118). You say that this equipment is medically necessary. The Plan denied your request. The Plan says this equipment is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that a Platform Crutch is not covered by Medicare as it is not primarily medical in nature. While this item may be appropriate for your use, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a lower leg platform crutch (E0118).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve continued IRF care. You say that an extended IRF stay is necessary while waiting on skilled nursing facility (SNF) placement. The Plan denied your request. The Plan says an IRF extension is not reasonable and necessary.
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. 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, multi-disciplinary 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 a continued 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 continued inpatient psychiatric care from November 9, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee is still disoriented and delusional. She does not have a safe place to go upon discharge and is not stable at this time. The Plan denied your request. The Plan says as of November 9, 2021, the enrollee does not meet the criteria for continued psychiatric care at the inpatient level. The enrollee is stable and ready for discharge to a lower level of care.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on October 23, 2021, with Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance and Acute Psychosis. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to herself or others and was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Based upon review, the records provided for the admission of this enrollee do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 9, 2021, forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 9, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 5, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician.
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician about the provided services and document the consent or declination date to consultations and date of the consultations in the patient's medical record.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, the submitted claim does not include a referring physician. Additionally, the medical records do not indicate that the member's attending or primary care physician was consulted about the services rendered. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies (99072, A4550, A4556, A4557, A4649, A9999,
A4624, E0776, E0780, E1399) and drugs (J3490), provided on November 25, 2020.
You asked the Plan to pay for supplies and drugs. You say that this should be covered as in-network. The Plan
denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that Medicare makes a separate payment for supplies
furnished in connection with a procedure only in the specific situations detailed in the rules section. The rules
also say that field 19 of the claim form must be populated with the drug's name and dosage when submitting a
claim for Not Otherwise Classified (NOC) drugs.
We looked at the file and Medicare rules. The supplies at issue were not used in the specific covered situations,
and field 19 of the claim was not populated with the name and dosage of the drug at issue. Based on this
information, we decided that Medicare rules for coverage of supplies and drugs have not been met. Therefore,
we decided that the Plan does not have to pay for supplies (99072, A4550, A4556, A4557, A4649, A9999,
A4624, E0776, E0780, E1399) and drugs (J3490), provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 23, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained.

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 referring provider is also not a network provider with the Plan. The Plan had network providers available who could have provided the services 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 drug testing services provided on June 23, 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 the rebase complete maxillary denture (D5710) and mandibular implant /abutment supported removable denture for edentulous arch (D6111) provided on May 5, 2021.
You asked the Plan to pay for the rebase complete maxillary denture and mandibular implant /abutment supported removable denture. You say that you believe these services were medically necessary and were not just for cosmetic purposes. The Plan denied your request. The Plan says these services are not listed as covered 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 the rebase complete maxillary denture (D5710) and mandibular implant /abutment supported removable denture for edentulous arch (D6111) provided on May 5, 2021