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

 We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the acupuncture services. You say that the acupuncture is medically necessary. You say you are in the process of becoming an in-network provider. The Plan denied your request. The Plan says the provider is out-of-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 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 acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture.  You asked the Plan to pre-approve a partial lower denture. You say that you feel you should receive proper care. You say that you are in pain and cannot eat. You also say that the denial of these services is causing difficulty to your daily routine. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan also says that the maximum benefit has been reached.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a partial lower denture and crown have not been met. Specifically, the file shows that the Plan approved the allowed amount of $530 for a partial upper denture and $470 towards the crown for tooth # 11. $530 + $470 = $1,000. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services from November 6 through November 10, 2021.  You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care through the date requested. The Plan denied your request. The Plan says the SNF care which remains in dispute 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a standby assist level with functional mobility including gait to 250 feet. The enrollee required varying assist with activities of daily living. There were no identifiable skilled nursing service needs as of November 6, 2021. There were no identifiable skilled therapy service needs as of November 6, 2021. The enrollee did not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services from November 6 through November 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).  You asked the Plan to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). You say that the science supporting this treatment is far great than many other procedures coverage is provided. You say that this procedure fills a treatment gap for patients who do not receive adequate relief from traditional conservative methods and the procedure should be authorized. The Plan denied your request. The Plan says Medicare does not cover unproven and not medically necessary procedures 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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental and more research is needed.  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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
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 has a medical and functional need for IRF. 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 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 enrollee has a need for physical and/or occupational therapy, there is no documented need for an intensive 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 24, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 72-year-old female with dementia who was transported from the hospital to the skilled nursing facility following PEG tube replacement in the hospital. She was moved via cot/sheet. Her vitals were stable. The enrollee was transported without incident or need for treatment. The documentation does not support that other means of transport (such as stretcher van) were contraindicated. Supervision and restraints could have been utilized with a stretcher van. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. No treatment was needed or received. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an odontoplasty (D9971) to be provided by a participating provider.  You asked the Plan to pre-approve odontoplasty. You say that you need this done because your tooth is hurting you. The Plan denied your request. The Plan says the requested service 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 odontoplasty (D9971) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) segmental pneumatic appliance (E0667).  You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are the only manufacturer and only supplier of the Flexitouch pneumatic compression device. This device prescribed for the enrollee cannot be obtained through an in-network provider. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) segmental pneumatic appliance (E0667).
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 enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF or that the patient can tolerate the intensity of therapy 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve low frequency, non-contact, non-thermal ultrasound.  You asked the Plan to pre-approve low frequency, non-contact, non-thermal ultrasound. The Plan denied your request. The Plan says this service is not medically 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 low frequency, non-contact, non-thermal ultrasound. Our reviewer says that the requested low frequency, non-contact, non-thermal ultrasound is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is insufficient high quality scientific or clinical evidence available to consider this device as reasonable and necessary for the treatment of wounds as it was intended for you. Therefore, without sufficient support made for this request, the low frequency, non-contact, non-thermal ultrasound will be considered not medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of low frequency, non-contact, non-thermal ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve low frequency, non-contact, non-thermal ultrasound.
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 enrollee does not require at least 3 hours a day, 5 days a week, or 15 hours over 7 consecutive days, of therapy services. There is not a reasonable expectation that the enrollee in this case will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF at this time.  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 anesthesia services (procedure code 00560) provided to the enrollee on April 6, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a surgical code that appropriately crosswalks to the anesthesia services must be reported to support the anesthesia code.  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 00560 is "Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator."  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 documentation includes a hard to read handwritten anesthesia report, which documents a "Pulmonary emboli estraction" was performed. No operative report, or pre and post anesthesia care documentation was included. Therefore, anesthesia services for procedures on the heart, pericardial sac, and great vessels of chest cannot be confirmed.   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 anesthesia services (procedure code 00560) provided to the enrollee on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vimpat.  You asked the Plan to pre-approve Vimpat. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  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 Vimpat.   Benefits for Vimpat may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator (E1392).  You asked the Plan to pre-approve an Inogen portable oxygen concentrator. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Inogen portable oxygen concentrator have not been met. Specifically, the case record does not support the medical necessity of the specific brand of the requested item. Therefore, we decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided September 19, 2020 to September 22, 2020.  You asked the Plan to pay for the inpatient care. You say that the correct DRG was billed. The Plan denied your request. The Plan says the records do not support the billed DRG.  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 DRG 193. 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 inpatient care. Our reviewer says that the records do not support DRG 193. Our physician reviewer found the patient was stable and did not qualify for the diagnosis of acute respiratory failure with hypoxia due to lack of respiratory distress or need for 5L or more of oxygen. Therefore, the records do not support DRG 193 but do support DRG 194.   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 inpatient care provided September 19, 2020 to September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Myrbetriq (J8499).  You asked the Plan to pre-approve Myrbetriq. You say that Myrbetriq is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  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 Myrbetriq (J8499).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a specialist office visit (99203) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a specialist office visit. You say that you are not feeling well, and you feel it is important that you be seen by the provider who performed your heart surgery 3 years ago. The Plan denied your request. The Plan says the provider you requested is not a network provider. The Plan also says that they determined that a network provider can care for your medical problem.  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 specialist office visit (99203) to be provided by an out-of-network (OON) provider.