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

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) for tooth #22.
You asked the Plan to pre-approve the post and core. You say that this service is necessary, and you cannot afford the cost. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) for tooth #22.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee
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 enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you need to continue using a ventilator and require an LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval.
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 that the enrollee appears to be unstable at this time and requires short-term additional acute care services that can be safely administered at the current facility. 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. Transfer to LTACH will be considered not medically necessary at this time as it would not be clinically advantageous. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system, enhanced steering, and
phone holder.
You asked the Plan to pre-approve a power seat elevation system, enhanced steering, and phone holder. You
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
requested items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules also say that a power seat elevation feature (E2300) is non-covered.
The requested phone holder at issue in this appeal does not serve a purpose that is primarily medical in nature.
A power seat elevation feature is non-covered. The requested enhanced steering is unbundled from the
approved power wheelchair and accessories. This cannot be requested separately. 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 power seat elevation system, enhanced steering, and phone holder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical
record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve Aduhelm. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Aduhelm. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the hospital observation services provided from June 25, 2021, through June 27, 2021.
You asked the Plan to pay for the hospital observation services. You say that this claim was properly reported with the correct POS code and should be paid. The Plan denied your request. The Plan says that a claim was received for an inpatient admission June 24, 2021, to June 30, 2021. This means that reporting the outpatient POS code is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that hospitals must include outpatient services provided three days preceding admission on the inpatient claim. However, the rules for selecting a POS code state that the place the face-to-face service is received should be used. In this case, the physician is billing for outpatient observation services, which would only be payable under the reported POS code 22. Though the hospital is required to include dates spent in outpatient observation on the inpatient claim, at the time of the face-to-face service, the enrollee was still outpatient. The Plan showed only a single page of the inpatient claim readout which does not include the date admitted to inpatient status. There is not sufficient information to support that the enrollee had been formally admitted as an inpatient for the three dates of service at issue. Therefore, the Plan's denial based on invalid POS code is not substantiated. Therefore, we decided that the Plan has to pay for the hospital observation services provided from June 25, 2021, through June 27, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
You asked the Plan to pre-approve a CT scan of the heart. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Medicare does not cover a screening CCTA for asymptomatic patients, for risk stratification or for quantitative evaluation of coronary calcium. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the heart. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of bupivacaine hydrochloride provided on January 28, 2021, billed with code S0020.
You asked the Plan to pay for the services as billed. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says both valid codes were paid. However, S0020 is not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code S0020 has a status indicator of "I" in the Physician Fee Schedule which means that it is invalid for
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the injection of bupivacaine hydrochloride provided on January 28, 2021, billed with code S0020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SPR Sprint percutaneous nerve stimulator (PNS).
You asked the Plan to pre-approve Sprint PNS. You say that this is covered by Medicare and is medically
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because this is not a Medicare-covered benefit.
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 Sprint PNS. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is insufficient medical literature to support use of this device 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 Sprint PNS have not been met. Therefore, we decided that the Plan does not
have to pre-approve SPR Sprint percutaneous nerve stimulator (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an acupuncture visit.
You asked the Plan to pay for an acupuncture visit. You say that you want to avoid a copayment. The Plan denied your request. The Plan says this is not a covered benefit for your condition.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the requested acupuncture visit is being requested for an injured rotator cuff. Acupuncture services are only covered for chronic low back pain. Therefore, we decided that the Plan does not have to pay for an acupuncture visit
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like to do inpatient rehabilitation for prosthetic training once your new prosthetic is available. The Plan denied your request. The Plan says the requested IRF admission 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 provided documentation does not indicate that you have complex nursing or rehabilitation needs. The reviewer found that while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Therefore, the reviewer found that the requested IRF admission is not medically reasonable or 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 IRF care have not been met. Specifically, the file does not indicate there is a need for an intensive rehabilitation program. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on April 2, 2021.

You asked the Plan to pay for lab tests. You say that you performed the tests ordered by the referring physician. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because predictive screening testing is not a Medicare benefit.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network physician. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on April 2, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bridge comprised of retainer crowns (D6740) and pontics (D6245).
You asked the Plan to pre-approve the dental bridge. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental bridge comprised of retainer crowns (D6740) and pontics (D6245).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says this is experimental.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that payment
may be made for implanted peripheral nerve stimulators in which electrodes are surgically placed under the
skin around a nerve. The rules also say that acupuncture is only covered when provided for low back pain when
furnished by a licensed acupuncturist.
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an
implanted nerve stimulator because the device involve needles inserted around the nerves and not electrodes
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral
nerve stimulator
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home podiatry visit with nail debridement provided on February 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON podiatry services. You say that the medical records support that this service was necessary and should be paid. The Plan denied your request. The Plan says these OON services are available from network providers, and no authorization was requested to provide this OON.
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 the home podiatry visit with nail debridement provided on February 1, 2021 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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this setting is the most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy program with multiple visits from a rehabilitation doctor.
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 physician reviewer found that the enrollee was at a moderate assist level for sitting up, minimal assist for standing, standby assist for toilet transfers, and contact guard assist for functional mobility.
The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be willing to participate in, fifteen hours per week of rehabilitative services with regular physician evaluation. 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.