Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for LTACH services.  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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on August 18, 2021.  You asked the Plan to pay for the services. You say that the medical records substantiate the place of service performed. The Plan denied your request. The Plan says the place of service is inappropriate for this procedure.  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 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)."  We asked our coder 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 services at issue in this case were not supported by the medical records. Our reviewer found the provider reported place of service 22 On Campus-Outpatient Hospital. CMS assigned moderate sedation codes a Professional/Technical Component (PCTC) indicator "3" effective for dates of service on or after January 1, 2017. Technical components are not separately payable when performed by a physician in a facility setting because the facility has staff on hand to perform those services.   We looked at this coder'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 pay for moderate sedation services (procedure code 99153) provided to the enrollee on August 18, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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. Care at the skilled nursing facility level appears to be appropriate in this case.        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 pay for the domiciliary or rest home visit for the evaluation and management of a new patient (CPT code 99327) provided to the enrollee on September 2, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 domiciliary or rest home visit for the evaluation and management of a new patient (CPT code 99327) provided to the enrollee on September 2, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that an IRF is the most appropriate setting for this enrollee and is necessary to reach the desired outcomes. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met 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 pay for 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 medical records provided, 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. The enrollee does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more appropriate in this case.  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 pay for 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 admission to a long term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.  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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite, three surfaces (D2332), a resin-based composite, four or more surfaces (D2335) and an interim partial denture (D5820) provided on April 26, 2021, to May 12, 2021.  You asked the Plan to pay for a resin-based composite, three surfaces, a resin-based composite, four or more surfaces and an interim partial denture. You say that the provider never received a denial for this claim. You also say that you have Celiac Disease, an auto immune disease, and that it affects your teeth, causing cavities and dry mouth. You believe that this claim should be reconsidered. The Plan denied your request. The Plan says the services requested are not eligible for coverage under the medical 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 pay for a resin-based composite, three surfaces (D2332), a resin-based composite, four or more surfaces (D2335) and an interim partial denture (D5820) provided on April 26, 2021, to May 12, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve continuation of admission in a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you are still sick from coronavirus (COVID-19). The Plan denied your request. The Plan says that skilled services are no longer required, and continuation of skilled nursing facility services is not medically necessary.  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 the requested continuation of services is medically reasonable and necessary. Our physician reviewer found you qualify for ongoing SNF coverage. You do not have documented skilled nursing needs, but you do have documented skilled therapy needs. You were doing well with therapy, but are currently restricted to your room due to testing positive for CoViD-19. Ongoing daily skilled services are required to establish a maintenance program or to prevent deterioration of your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continuation of admission in a skilled nursing facility (SNF).   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the out-of-network virtual care services provided from August 3, 2021, to September 28, 2021.  You asked the Plan to pay for the services provided. You say that the claims were paid until recently. The Plan denied your request. The Plan says out-of-network virtual visits have no coverage.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).   We looked at the file and the rules. The Plan contract says that virtual care when provided out-of-network is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the out-of-network virtual care services provided from August 3, 2021, to September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show any problems with doing MRADLs in the home.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation indicates that you do not have adequate balance and safety to on and off the scooter. The documentation indicates the requested K0800 scooter will primarily be used for out of the home activities.  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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the back brace (L0650) and ankle foot orthosis (L1906) provided on October 22, 2020.  You asked the Plan to pay for the back brace and ankle foot orthosis. You say that you would like reconsideration because the back brace and ankle foot orthosis is medically necessary. The Plan denied your request. The Plan says the documentation does not support a need for the back brace and ankle foot orthosis.  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 pay for the back brace and ankle foot orthosis. Our reviewer says that the LCD L33790 criteria have not been met for an L0650  lumbosacral orthosis. The documentation does not reveal an objective physical examination of the lumbar spine or a detailed neuromuscular system. There is no evidence on a physical exam that indicates member's pain is reduced by restricting trunk mobility. There is no evidence of a recent injury or surgery to the spine or related soft tissues that requires the orthosis to facilitate healing. There is no evidence on an objective physical exam of weak or deformed spinal muscles. The requested L0650 lumbosacral orthosis is not medically necessary. Our physician reviewer found the LCD L33686 criteria have not been met for an L1906 ankle foot orthosis. The documentation does not reveal an objective physical examination of the ankle or foot or a detailed gait, musculoskeletal or neuromuscular system physical exam. There is no evidence on a physical exam that indicates the member is ambulatory. There are no objective physical exam findings of  weakness or deformity of the foot and ankle. There are no objective exam findings of instability supporting that the member requires the L1906 for requires stabilization for medical reasons, and that the L1906  has the potential to benefit the member functionally.  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 back brace and ankle foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the back brace (L0650) and ankle foot orthosis (L1906) provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nutri-pharmaceutical blend (J3411, J3415, J3490 and J3420) provided on May 4, 2020.  You asked the Plan to pay for the nutri-pharmaceutical blend. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the individual drugs within a compounded mixture are not separately billable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes J3411, J3415, J3490 and J3420 are not supported in the record. Specifically, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the nutri-pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for the nutri-pharmaceutical blend (J3411, J3415, J3490 and J3420) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Sanexas therapy and vitamin injections.  You asked the Plan to pre-approve the Sanexas therapy and vitamin injections. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the requested service 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 the Sanexas therapy and vitamin injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the services under review do not have a strong body of credible literature to support their efficacy in the management of neuropathic pain (or other forms of pain).  The services under review are not readily endorsed by any professional society guidelines at this time either. In this setting it cannot be said that these services are otherwise appropriate or indicated for your symptoms. Rather, given the lack of credible references these services would be better defined as being experimental.  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 Sanexas therapy and vitamin injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Sanexas therapy and vitamin injections.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Victoza for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication is denied as a benefit exclusion.  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 Victoza for the enrollee.