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

 We decided that the Plan does not have to pre-approve waterjet ablation of the prostate for the enrollee.  You asked the Plan to pre-approve the services.. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.  The Plan must follow Medicare rules. Medicare rules say that transurethral waterjet ablation of the prostate is only covered for enrollees 80 years old or younger.   The file shows that the enrollee is 83 years old. 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 pre-approve waterjet ablation of the prostate for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and have been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. Although you made progress with therapy, your functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting, such as a skilled nursing facility (SNF).  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for vertebral osteomyelitis. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 981 from October 9, 2019 to October 18, 2019.  You asked the Plan to pay for inpatient care. You say that the original DRG of 981 is more accurate for the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for inpatient hospital care at DRG 981 is correct, because the decision to sequence diagnosis code E11.51 as the principal diagnosis code and T87.81 as a secondary diagnosis code is correct.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with T87.81. 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 inpatient care. Our reviewer says that this inpatient stay does not meet criteria for payment at the requested DRG. Our physician reviewer found the documentation does not support diagnosis code T87.81 as the primary diagnosis for inpatient services. Documentation supports this condition was treated with dressing changes and wound vac application, however, during the course of the hospital stay, focus of treatment was for possible arterial occlusion as a angiogram was performed with treatment for occlusions of peripheral vessels.  As treatment was rendered for dehiscence of amputation, documentation supports T87.81 as a secondary diagnosis.   We looked at this review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care at diagnosis related group (DRG) 981 from October 9, 2019 to October 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the OsteoAmp Allograft.  You asked the Plan to pre-approve the OsteoAmp Allograft. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the Osteoamp allograft have not been demonstrated.  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 OsteoAmp Allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Osteoamp allograft remains experimental. More research is needed to show safety and efficacy of the product when used as bone graft material in the spine.  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 OsteoAmp Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve the OsteoAmp Allograft.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the abdomen (74183), to be provided by an OON provider.  You asked the Plan to pre-approve the MRI of the abdomen. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers available to perform this service.  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 the magnetic resonance imaging (MRI) of the abdomen (74183), to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these OON services. You say that you trust this provider's professional skills and would feel much comfortable under the care of this provider. The Plan denied your request. The Plan says the requested services can be provided by a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 the enrollee indicates that you have chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The records indicate that you have multi-level degenerative disease. The record does not document that you are not indicated for operative therapy at more than two levels. The records do not indicate that you have undergone at least six months of non-operative treatment. The elements of the coverage criteria are not satisfied.  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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot/knee, ankle rotation unit, and extra protective cover for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for K3 foot and ankle does not meet Medicare criteria as reasonable and necessary.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee meets Medicare criteria for this request, as there is no evidence that the enrollee is a K3 ambulator. The records from the enrollee's treating medical provider indicates that he is using a motorized wheelchair for mobility, which would not be consistent with a K3 level of ambulation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot/knee, ankle rotation unit, and extra protective cover for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services without transport (A0998) provided on May 25, 2021.  You asked the Plan to pay for ambulance services without transport. You say that it was not your decision to call the ambulance but that of the urgent-care doctor and that the responsibility for the charges should lie with the urgent-care doctor. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. Medicare has instituted a waiver that allows payment for ambulance services when there is no transport in regions where facilities are overtaxed due to the Coronavirus pandemic.  The ambulance company did not provide transport services on May 25, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. No reference is made in the case record to regional facilities being overtaxed due to the Coronavirus pandemic on the date of service. The Medicare waiver does not apply in this case. Therefore, we decided that the Plan does not have to pay for ambulance services without transport (A0998) provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided from September 11, 2020, to September 13, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis codes M48.02 and G95.20. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the billed diagnosis codes are not supported. Our physician reviewer found that the use of primary diagnosis code M48.02 and secondary diagnosis code G95.20 were not supported by the records provided.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from September 11, 2020, to September 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy (D3310) provided by a participating provider.  You asked the Plan to pre-approve endodontic therapy. You say that you were told that a root canal was covered. The Plan denied your request. The Plan says the dental services requested are not a covered 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 endodontic therapy (D3310) provided by a participating provider.
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 you only require short-term additional acute care services that can safely be administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require 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: 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 this level of care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 based on the enrollee's current level of function, she does not require an intensive, complex, multidisciplinary approach to daily therapy. The enrollee needs physical therapy an occupational therapy in an alternate low-intensity setting such as a skilled nursing 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an occlusal guard (D9944).  You asked the Plan to pre-approve an occlusal guard. You say that you are unable to pay for an occlusal guard. The Plan denied your request. The Plan says the requested item is not a covered 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 an occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the occlusal guard, hard appliance, full arch (D9944).  You asked the Plan to pre-approve the occlusal guard. You say that this device by no means has an aesthetic purpose. You have been diagnosed with severe teeth grinding and clenching. The lower portion of your frontal five teeth already show rapid deterioration. The Plan denied your request. The Plan says the requested service is not covered under the Plan 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 pre-approve the occlusal guard, hard appliance, full arch (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that  The Plan denied your request. The Plan says care is available within the 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.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a hereditary cardiovascular panel (81286, 81238, 81410, 81411) provided on April 14, 2021.  You asked the Plan to pay for a hereditary cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered. The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.  We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular panel (81286, 81238, 81410, 81411) provided on April 14, 2021.