Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an magnetic resonance imaging, upper extremity, other than joint (73218) and an magnetic resonance angiography, head (70544) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the diagnostic services. You say that please reconsider the decision to deny coverage of this medically necessary diagnostic procedure. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 an magnetic resonance imaging, upper extremity, other than joint (73218) and an magnetic resonance angiography, head (70544) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that it is too soon for you to be discharged. The Plan denied your request. The Plan says you can be treated at a lower level of care.
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.termine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not show evidence of complex wound care, new enteral feedings, or other skilled nursing needs. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services on a daily basis in a SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-emergent ambulance transport (A0428).

You asked the Plan to pre-approve the ambulance transport. You say that the transportation is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 pre-approve the ambulance transport. Our reviewer says that the ambulance transport is not medically necessary. Our physician reviewer found the request is for ambulance transport to and from dialysis. The provided records do not show that other means of transportation, such as stretcher van, are contraindicated. The enrollee does not require the services of skilled ambulance personnel. 

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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-emergent ambulance transport (A0428).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutritional counseling services.

You asked the Plan to pre-approve nutritional counseling services. You say that you have Celiac disease and need a nutritionist specialist. The Plan denied your request. The Plan says the requested medical nutrition therapy is not medically necessary as the enrollee does not have diabetes or kidney disease.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve nutritional counseling services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 26, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The 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 lab services provided to the enrollee on March 26,
2021.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the records show that the enrollee's needs are met in the current inpatient 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve stimulator trial (64555).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is considered to be experimental and investigational and therefore, not covered.
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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a diagnosis of chronic pain syndrome. On August 19, 2021, the enrollee was seen for routine medication refills. The enrollee was stable on her medications.
The documentation provided in this case is insufficient to demonstrate that the enrollee has pain which is refractory to conventional treatment measures such as physical therapy, medications, transcutaneous electrical nerve stimulation, and nerve blocks. It has not been sufficiently established in the medical documentation that a peripheral nerve stimulator trial is medically reasonable and 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral nerve stimulator trial (64555).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a retainer crown - porcelain fused to noble metal (D6752) for tooth #4 and a pontic - porcelain fused to noble metal (D6242) for tooth #3.

You asked the Plan to pre-approve a retainer crown for tooth 4 and a pontic for tooth 3. You say that the new bridge is medically necessary. The Plan denied your request. The Plan says that provider requested D6752 (retainer crown) for a tooth that is not present (#3) and requested D6242 (pontic) for a tooth that is present (#4) - neither of these procedures are possible or permissible.

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. The Plan covers a retainer crown for tooth 4 and a pontic for tooth 3 when the services are medically necessary and reasonable. 
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 retainer crown for tooth 3 and a pontic for tooth 4. Our reviewer says that a retainer crown for tooth 4 and a pontic for tooth 3 are medically reasonable and necessary. Our physician reviewer found that an appeal is being made for the denial of coverage for the replacement of missing tooth #3 with a fixed bridge. The reason for the denial was that there appears to be confusion as to the retainer crowns and pontic. A review of the enrollee's dental record and radiographs indicate that a bridge replaced missing tooth #3 using retainer crowns on teeth #'s 2 and 4. Tooth #2 was extracted leaving no distal retainer crown therefore compromising the function of the bridge. A new bridge is needed to replace missing tooth #3 using #'s 4 and 5 as retainer crowns (D6752) and a cantilever pontic replacing #3 (D6242). The dental record verifies this treatment plan and the criteria for coverage have been met.

We looked at this physician's review, the file, and Medicare rules. The appeal request on August 12, 2021, explains that the enrollee needs to have part of a bridge removed and a new bridge #3-5 to support #3 cantilever (pontic). Based on this information, we decided that the Plan's rules for coverage of a retainer crown for tooth 3 and a pontic for tooth 4 have been met. Therefore, we decided that the Plan has to pre-approve a retainer crown - porcelain fused to noble metal (D6752) for tooth #4 and a pontic - porcelain fused to noble metal (D6242) for tooth #3.

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: 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 treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 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 inpatient rehabilitation 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 pay for the limited oral evaluation provided on June 24, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that they took x-rays and did nothing else.
The Plan denied your request. The Plan says the 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 pay for the
limited oral evaluation provided on June 24, 2021.

Your complaint about being very disappointed is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the MyoPro powered arm brace (E1399).

You asked the Plan to pay for the brace. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered incorrect coding.

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 E1399 is "durable medical equipment, miscellaneous." 

We find that procedure code E1399 is not supported in the medical record. Specifically, L8702 has already been requested and approved. This code completely describes the device. E1399 is incorrect coding and unnecessary for this request. Based on this information, we decided that Medicare rules for coverage of the brace have not been met. Therefore, we decided that the Plan does not have to pay for the MyoPro powered arm brace (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you need to wear these stockings 24 hours a day, 7 days a week. The Plan denied your request. The Plan says this does not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar fusion procedure (C1821, 22612, 22614).

You asked the Plan to pre-approve the spinal procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this type of lumbar fusion procedure is investigational and is not covered.

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 spinal procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Stabilink MIS interlaminar device is experimental. More research is needed to show safety and efficacy of the device. 

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 spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar fusion procedure (C1821, 22612, 22614).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February
1, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you required ambulance
services due to having the coronavirus and feel that the copayment should be waived. The Plan denied your
request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75
copayment for ambulance services.

You have been asked to pay a $75 copayment for ambulance services. Ambulance services fall within the
ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services
provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Specifically, the request is for a fluid circulating cold pad with pump, which is not a covered benefit under Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (CPT code 91110), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Review of the file shows that the enrollee has a pacemaker, making the procedure inadvisable. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (CPT code 91110), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic knee components (L5981, L5986, L5814, L5850, and l5845).

You asked the Plan to pre-approve the prosthetic knee components. You say that the knee components for K3 should be covered. The Plan denied your request. The Plan says the documentation does not support that the enrollee is a K3 ambulator.

The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files. The documentation from the enrollee's treating practitioner shows that the enrollee is a K2 ambulator, so the enrollee does not meet coverage criteria for these knee components, as they are only covered for K3 ambulators. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthetic knee components have not been met. Therefore, we decided that the Plan does not have to pre-approve the prosthetic knee components (L5981, L5986, L5814, L5850, and l5845).