Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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 treated for a right ankle fracture. 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 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 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright/stand up walker.
You asked the Plan to pre-approve an upright/stand up walker. You say that you have your current walker up as far as it can go and you are still hunched over. The Plan denied your request. The Plan says you have a current wheeled walker.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a walker. Your current walker serves the same purpose as an upright/stand up walker. The Plan notes that the provider can assist you with adjusting the walker you recently received to a more comfortable height and determine if this walker is appropriate for your needs. Therefore, we decided that the Plan does not have to pre-approve an upright/stand up walker.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says there is a significant risk of accessing the spinal cord without a good expectation of benefit or positive outcome.
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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there has not been a documented trial of a stimulator. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), guided tissue regeneration (D4266 x 4), alveoloplasty with extractions (D7310 x 2), endosteal implants (D6010 x 2), and bone grafts (D6104 x 2) provided on February 8, 2021.
You asked the Plan to pay for the dental services. You say that you were advised that implants were covered at 100%. You say that you are on a low-income subsidy. You also say that you would not have had these services done had you known they would not be covered. The Plan denied your request. The Plan says 1 alveoloplasty with extractions is covered per year. The Plan says 2 endosteal implants are covered per year. The Plan says 2 bone grafts at time of implant placement are covered per year. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that the consultation and guided tissue regeneration are not listed as covered services.
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 and alveoloplasty with extractions, endosteal implant, and bone graft at time of implant placement are listed as covered, the frequency limits for these services have been exceeded. The record shows that the Plan paid for 1 alveoloplasty with extractions, 2 endosteal implants, and 2 bone grafts at time of implant placement on the date of service in this case. Additionally, the consultation and guided tissue regeneration are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310), guided tissue regeneration (D4266 x 4), alveoloplasty with extractions (D7310 x 2), endosteal implants (D6010 x 2), and bone grafts (D6104 x 2) provided on February 8, 2021.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a SNF stay. We decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for a SNF stay. You say that you were not aware of the 60 day benefit period. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $1,150 to $1,100.
You had a SNF stay from April 8, 2021, to April 30, 2021. The record shows that you had a previous SNF stay for over 20 days. Therefore, you are responsible to pay a $50 copayment for SNF days received from April 8, 2021, to April 29, 2021 for a total of 22 days. The total amount you owe is: $50 (copayment) x 22 (SNF days) = $1,100. Pease note, you cannot be charged a copayment for the day you were discharged. The Plan says that you must pay $1,150 for a SNF stay. However, you cannot be asked to pay more than $1,100. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $1,150 to $1,100.
We also decided that the Plan does not have to waive the copayment for a SNF stay.
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 $0 copayment for days 1-20 and a $50 copayment for days 21-100, per benefit period for a SNF stay.
You had a SNF stay from April 8, 2021, to April 30, 2021. The record shows that you had a previous SNF stay for over 20 days. Therefore, you are responsible to pay a $50 copayment for the SNF days received from April 8, 2021, to April 29, 2021 for a total of 22 days. The total amount you owe is: $50 (copayment) x 22 (SNF days) = $1,100.
Therefore, we decided that the Plan does not have to waive the $1,100 copayment for a SNF stay.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and associated appliances (E0667).
You asked the Plan to pre-approve a pneumatic compression device and associated appliances. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for this device.
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) and associated appliances (E0667).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve dilation of the eustachian tube.
You asked the Plan to pre-approve dilation of the eustachian tube. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve dilation of the eustachian tube. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been diagnosed with eustachian tube dysfunction. The enrollee's symptoms were on the left side and physical exam showed changes to the tympanic membrane due to the underlying dysfunction. The Academy of Otolaryngology has published guidelines regarding the treatment of eustachian tube dysfunction and the use of a balloon dilation system to improve eustachian tube dysfunction. The enrollee meets the criteria set by the Academy regarding the use of a balloon dilation. The Academy recommends performing a balloon dilation in enrollees with dysfunction who do not improve with medical management. Unfortunately, as states in the guidelines, there is no standard medical management of eustachian tube dysfunction as nasal sprays rarely work. Therefore, the above procedure is considered standard of care for this diagnosis and should not be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dilation of the eustachian tube have been met. Therefore, we decided that the Plan has to pre-approve dilation of the eustachian tube.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (POV).
You asked the Plan to pre-approve a Group 1 standard power operated vehicle (K0800). You say that because of chronic pain you need a POV. The Plan denied your request. The Plan says criteria was not addressed by your provider.
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. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file does not show that you do not have a mobility deficit that impairs your participation in MRADLs or you can safely operate the POV being requested.
The POV at issue in this appeal is being requested for use outside of the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (POV).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN (G0299) and direct skilled nursing services of an LPN (G0300).
You asked the Plan to pre-approve the direct skilled nursing services of a RN and LPN. You say that you need help being monitored daily. You also say that you feel taking away your visits will be life threatening because
you are not a medical professional. The Plan denied your request. The Plan says you do not meet the criteria for approval.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 direct skilled nursing services of a RN and LPN. Our reviewer says that the direct skilled nursing services of a RN and LPN are not medically necessary for the enrollee. Our physician reviewer found the visiting nurse draws up your insulin for you. Our reviewer found that there appears to be no reason why the insulin needs to be drawn up daily, rather than weekly. Our physician reviewer also found that there is no evidence of other skilled nursing needs. 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 direct skilled nursing services of a RN and LPN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a RN (G0299) and direct skilled nursing services of an LPN (G0300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on
April 28, 2021.

You asked the Plan to pay for physical therapy. You say that the appeal should be reviewed, and authorization
should be provided. The Plan denied your request. The Plan says prior authorization for out-of-network
services was required but not obtained.

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 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 physical therapy provided by an out-of-network
provider on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutments (D6057 x 2), abutment
supported crowns (D6058 x 2), and pontics (D6245 x 2) provided on May 25, 2021.
You asked the Plan to pay for the dental services. You say that you fell, and your teeth were knocked out. You
say that your jaw and face were injured due to the fall. You say that you need this dental work due to it being 1
front tooth and 2 next to your front tooth that were knocked out. The Plan denied your request. The Plan says
custom fabricated abutments, abutment supported crowns, and pontics are not covered unless they are related to
surgery of the jaw or facial bone.
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 services you received are not
among those covered under this benefit. The services you are asking the Plan to pay for involve the care,
treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These
are dental services that are not covered or paid for by Medicare. Additionally, the record shows that the
services are not related to jaw or facial surgery. Therefore, we decided that the Plan does not have to pay for
the custom fabricated abutments (D6057 x 2), abutment supported crowns (D6058 x 2), and pontics (D6245 x
2) provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following the left total knee arthroplasty (CPT code 27447), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the planned procedure listed under CPT code 27447 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan says if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights.
In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record did not show that the admitting physician reasonably expects that the patient's necessary hospital care will span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care following the left total knee arthroplasty (CPT code 27447), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal with reinsertion, non-biodegradable drug delivery implant coded 11983, the removal of posterior segmental instrumentation coded 22852, and the arthrodesis services coded 22633 and 22612 provided on March 8, 2021.
You asked the Plan to pay for the removal with reinsertion, non-biodegradable drug delivery implant, the removal of posterior segmental instrumentation, and the arthrodesis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says multiple physicians/assistants are not covered in this case.
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 11983, 22852, 22633, and 22612 are not supported in the medical record. Specifically, the documentation shows that assistant surgeon services were previously processed and paid by the Plan. Multiple physician/assistants are not covered for the services rendered. Based on this information, we decided that Medicare rules for coverage of the removal with reinsertion, non-biodegradable drug delivery implant, the removal of posterior segmental instrumentation, and the arthrodesis services have not been met. Therefore, we decided that the Plan does not have to pay for the removal with reinsertion, non-biodegradable drug delivery implant coded 11983, the removal of posterior segmental instrumentation coded 22852, and the arthrodesis services coded 22633 and 22612 provided on March 8, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a spinal puncture. We decided that the Plan
does not have to reduce the cost-sharing charges for a spinal puncture to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for a spinal puncture. You say that not enough spinal
fluid was taken so the test was incomplete. The Plan says that the claims were processed correctly, and you are
being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for a spinal puncture from $60 to $45.
Your contract with the Plan clearly says that you must pay a $45 copayment for specialist services, including
surgery services.
The Plan says that you must pay a $60 copayment. However, you cannot be asked to pay more than a $45
copayment for a spinal puncture provided by a specialist. Therefore, we decided that the Plan has to reduce the
cost-sharing charges for a spinal puncture from $60 to $45.
We also decided that the Plan does not have to waive the $45 copayment for a spinal puncture.
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 $45 copayment for specialist services, including
surgery services.
You received a spinal puncture on May 4, 2021, from a specialist. A spinal puncture is considered a surgical
procedure. Therefore, you are responsible to pay the $45 copayment. Therefore, we decided that the Plan does
not have to waive the $45 copayment for a spinal puncture.
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.