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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care at the current facility, and these services will continue to be covered. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which the LTACH may offer a therapeutic advantage.  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 is currently undergoing treatment at an acute care hospital for breakthrough seizures. The enrollee has been discharged from the acute care hospital and there is no evidence that the enrollee requires the services available at the LTACH. The enrollee can be discharged to a lower level of care for any ongoing long term care 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 14, 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 this is considered experimental and investigational.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of testing has not been sufficiently shown via high quality studies to improve overall care and outcomes for patients over standard testing methods in the clinical situation such as this enrollee. Therefore, this request for the CxBladder Detect Test 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ondansetron tablets.  You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. Although the requested ondansetron is an oral anti-emetic drug, this drug is not being requested as a full therapeutic replacement for intravenous anti-emetic therapy that would have been administered at the time of chemotherapy treatment. 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 ondansetron tablets.   Benefits for self-administered drugs 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: 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 enrollee has been successfully weaned down to ll L High Flow Nasal Cannula and not requiring AIRVO. You say that the enrollee has been medically cleared by the care team at the acute care hospital and hemodynamically stable for transfer to a LTACH. You say that the enrollee is a high risk for readmission if discharged to a lower level of care. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute care and does not require transfer to a LTACH.  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 that the was admitted to the current acute care hospital with recent Coronavirus (COVID-19), recurrent pneumonia, Chronic obstructive pulmonary disease (COPD) exacerbation, and acute respiratory failure treated with AIRVO. He was treated with bronchodilators and required PEG tube feeds, Cardizem and metoprolol for chronic atrial fibrillation, antibiotics, and steroids. Recent notes show that the enrollee has been successfully weaned to high flow oxygen and is returning to his baseline. The enrollee is improving and is more stable and should only require short-term additional acute care services that can be safely received at the current facility until more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current acute care facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, the LTACH services will be considered not medically necessary as transfer would not be advantageous clinically compared to completing care at the current facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the evaluation and implants from an out-of-network dentist.  You asked the Plan to pre-approve the evaluation and implants. You say that this is causing your health issues and you do not agree with the denial. The Plan denied your request. The Plan says members are required to use network providers.  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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the evaluation and implants from an out-of-network dentist.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 an Intracept procedure. 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. More research is needed to show safety and efficacy of the procedure to treat back pain.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services provided to the enrollee from May 6, 2021 to May 18, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the type of bill is invalid for Prospective Payment System (PPS) claims. A corrected claim is needed for these services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due to an error with the type of bill code reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from May 6, 2021 to May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676) and segmental gradient pressure pneumatic appliance (E0673).  You asked the Plan to pre-approve a pneumatic compression device. You say that this should be a covered benefit. The Plan denied your request. The Plan says items that are used for a preventative service are excluded from coverage under the Medicare DME benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676) and segmental gradient pressure pneumatic appliance (E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an anterior apicoectomy (D3410), retrograde filling (D3430), biologic materials to aid in soft and osseous tissue regeneration (D3431), and bone replacement graft (D4263).  You asked the Plan to pre-approve the anterior apicoectomy, retrograde filling, biologic materials, and bone replacement graft. You say that it is medically necessary for you to receive this level of care. The Plan denied your request. The Plan says these services are not covered under your plan.  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 anterior apicoectomy (D3410), retrograde filling (D3430), biologic materials to aid in soft and osseous tissue regeneration (D3431), and bone replacement graft (D4263).
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 these services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need 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 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion services provided to the enrollee from May 4, 2021 to May 11, 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 Medicare guidance says that the appealed procedure code 99601 is an invalid procedure code for this service. Medicare uses another code for reporting of, and payment for these services. You can find this guidance in the Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 30.2 and 30.2.2.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to the use of an inappropriate code for Medicare claims. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services provided to the enrollee from May 4, 2021 to May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Genesight testing.  You asked the Plan to pre-approve Genesight testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.  The Plan must follow Medicare rules. Medicare rules say that Genesight testing is only covered for certain indications.  Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38394 to support their denial. However, this LCD is not valid for the enrollee's home state of Alabama. This means we are unable to use LCD L38394 to substantiate our decision.   We looked at the file and Medicare rules. While the enrollee does have a history of anxiety, the enrollee does not have a history of major depression. This means the enrollee does not have a diagnosis for which this testing is covered. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Genesight testing.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for air ambulance provided on April 29, 2021.  You asked the Plan to pay for air ambulance. You say that air ambulance services were medically necessary. The Plan denied your request. The Plan says air ambulance services were 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 air ambulance. Our reviewer says that the air ambulance service was not medically necessary. Our physician reviewer found that the enrollee had received treatment for her small cerebrovascular accident (CVA). She did not have a life-threatening condition or intra cerebral hemorrhage. The was no indication for additional emergent stroke care provided. The documentation did not support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 air ambulance have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve core buildup (D2950), surgical procedure for isolation of tooth with rubber dam (D3910) and unspecified endodontic procedure (D3999).  You asked the Plan to pre-approve core buildup (D2950), surgical procedure for isolation of tooth with rubber dam (D3910) and unspecified endodontic procedure (D3999). You say that your plan covers root canals and you already paid $957. You say that this is a covered service and want to know why insurance is paying nothing. The Plan denied your request. The Plan says the services are not covered benefits.    Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950), surgical procedure for isolation of tooth with rubber dam (D3910) and unspecified endodontic procedure (D3999).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart without contrast material, with quantitative evaluation of coronary calcium (75571).  You asked the Plan to pre-approve the requested CT scan. You say that this requested scan is medically reasonable and necessary. The Plan denied your request. The Plan says this is not a covered service under the Plan or Medicare. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the requested CT scan, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services provided to the enrollee from April 2, 2021 to April 7, 2021 billed under code S9502.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says code S9502 is assigned a status code of "I" and is not eligible for payment on Medicare claims.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code reported has a status indicator that prevents payment on Medicare claims. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from April 2, 2021 to April 7, 2021 billed under code S9502.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the upper denture.  You asked the Plan to pre-approve the upper denture. You say that you require dentures since the extractions have taken place. You say that you are willing to share the cost but prefer the dentures to be fully covered. 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 pre-approve the upper denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cooled radiofrequency ablation services.  You asked the Plan to pre-approve the requested services. You say that cooled radiofrequency ablation is the preferred method of radiofrequency lesioning. The Plan denied your request. The Plan says the service is not reasonable or necessary.   The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.   We looked at the file and Medicare rules. Non-thermal modalities for facet joint denervation are considered not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation services.