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

 We decided that the Plan does not have to pre-approve methotrexate tablets.  You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been on this medication for longer than 10 years and his condition is well-controlled. 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. 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 methotrexate tablets.   Benefits for self-administered drug 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 compression stockings identified with code A6530.  You asked the Plan to pre-approve the compression stockings. You say that your doctor ordered the item. The Plan denied your request. The Plan says the services are not covered.  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: 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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in home with therapies. 

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 provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation trips to continue seeing specialists. The Plan denied your request. The Plan says you have exhausted the transportation benefit for 2021.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shringrix vaccine and administration provided from March 20, 2021, through June 19, 2021.

You asked the Plan to pay for the vaccine services. You say that you would like this claim reprocessed for payment under the medical benefit. The Plan denied your request. The Plan says this immunization is not among those covered under your medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the vaccine services. Therefore, we decided that the Plan does not have to pay for the Shringrix vaccine and administration provided from March 20, 2021, through June 19, 2021.

Benefits for the vaccine services 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra 5% drops.  You asked the Plan to pre-approve Xiidra. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefits.  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 Xiidra 5% drops.   Benefits for Xiidra 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Corplex and Revita skin substitute grafts.  

You asked the Plan to pre-approve skin substitute grafts. You say that the enrollee has an open wound and therapy is not working. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the documentation does not support 30 days of failed comprehensive wound care.  

The Plan follows Medicare rules. Medicare rules state that skin substitute grafts may be covered under certain conditions.   

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 skin substitute grafts. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of skin substitute grafts. Our physician reviewer found the enrollee has a diabetic toe ulcer. The record does not indicate a 30-day trial and failure of standard therapy. The record does not include an evaluation of arterial circulation. The record shows a decrease in wound size since the initial debridement. Therefore, the requested use of skin substitute grafts is not recommended.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin substitute grafts have not been met. Therefore, we decided that the Plan does not have to pre-approve Corplex and Revita skin substitute grafts.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wrist surgery services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve wrist surgery services. You say that this request is medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide these services.

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 wrist surgery services to be provided by an out-of-network (OON) provider.
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 would be best served in an IRF, and these services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a fully electric hospital bed.  You asked the Plan to pre-approve the fully electric hospital bed. You say that you are not able to get up or down in a normal bed. You say that you are currently only able to sleep in your wheelchair so that you can elevate your legs. You say that the clinical documentation provided supports the need for the requested total electric hospital bed. The Plan denied your request. The Plan says the item in dispute is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental implant placements (D6010) for teeth #4 and #5 and a bone graft at the time of implant placement (D6104).  You asked the Plan to pre-approve dental implants. You say that these services are necessary to protect your other teeth. The Plan denied your request. The Plan says these services are not covered by your dental 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 implant services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental implant placements (D6010) for teeth #4 and #5 and a bone graft at the time of implant placement (D6104).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injection services.

You asked the Plan to pre-approve the epidural steroid injection services. You say that the enrollee has been doing home exercises as well as Yoga. You say that the enrollee has been to a surgeon and would like to try injections before opting for surgery. You say that the enrollee is experiencing worsening pain and needs to have the requested injection services. The Plan denied your request. The Plan says that the requested injection is not supported before a trial of treatment.

The Plan follows Medicare rules. Medicare rules say that ESI injection services are covered when medically reasonable and 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 the epidural steroid injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has spinal stenosis with neurogenic claudication. The progress notes documents of failure to respond to four weeks of noninvasive conservative care (Home Exercise and Yoga). The requested ESI services are 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 the epidural steroid injection services have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injection services.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 14, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the $1000 maximum benefit was exhausted prior to this date of
service. We overturned the Plans denial for insufficient claim information in the case file to show this
benefit had been paid. The Plan requested a reopen and provided the required documentation. The Plan states
that the documentation shows this benefit was exhausted for services provided on February 11, 2021.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Based on the records
provided by the Plan, though the Plan offers a dental benefit in excess of Medicare coverage, the maximum
dental benefit of $1000 was exhausted prior to this date of service. Therefore, we decided that the Plan does
not have to pay for dental services provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve the sclerotherapy services.  You asked the Plan to pre-approve sclerotherapy services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been satisfied.  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 sclerotherapy services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is satisfactory documentation available that indicates that treatment is medically necessary.  There is satisfactory documentation that it is believed that this is a venous stasis ulcer; at the medial ankle with associated hyperpigmentation. The patient does have a history of severe peripheral artery disease (PAD) and is status post right above-knee amputation. The above-knee portion of the left greater saphenous vein was already harvested in an effort to treat the right leg. It is documented that the remnant greater saphenous vein in the calf is enlarged and associated with large varicosities under the ulcer. While the pulse examination is dubious (as palpable pedal pulses in the amputated leg are documented), there is an ankle brachial index (ABI) suggesting normal tibial waveforms and was read as normal. Treatment of the varicosities under the ulcer with sclerotherapy may indeed help with ulcer healing and, in this case, it would not be medically necessary to insist on a period of conservative treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy services have been met. Therefore, we decided that the Plan has to pre-approve the sclerotherapy services.   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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).

You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that you
tried chiropractic, massage, acupuncture, stem cell implants and a spinal cord stimulator with no relief. You say
that the doctor was certain this procedure could give you relief from the severe pain and the procedure should
be reconsidered. The Plan denied your request. The Plan says the services are 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 the insertion of stabilization device
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found that interlaminar spacer devices are
experimental. More research is needed to show safety and efficacy.

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 insertion of stabilization device (22869 and 22870) have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869
and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wound care supplies (A6446).  You asked the Plan to pre-approve the supplies. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation by the physician of the presence of a qualifying wound, recent surgery or debridement.  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 supplies.  Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, there is no documentation by the physician of the presence of a qualifying wound, recent surgery, or debridement. You have a past history of qualifying wounds prior to 2020 but there is no documentation of the presence of current qualifying wounds.  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 supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care supplies (A6446).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for osteotomy of the tibia (27705) billed to the enrollee for date
of service April 19, 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 Medicare billing criteria were not met. We overturned the Plans denial. The Plan
requested a reopen and provided additional information. The Plan says that according to code definitions and
guidance, code 27705-51-LT is not supported in the documentation and therefore is not payable. The Plan there
are certain types of improper coding that physicians must avoid. Procedures should be reported with the most
comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. The Plan
states that the code description was documented in the operative report narrative; however, this procedure is
inclusive to the main procedure. Procedure code 2770551LT would be considered inclusive to procedure code
2872551LT. Therefore, the requested code 2770551LT cannot be paid as billed.
The Plan is correct 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 codes. In this case, we have
confirmed that code 27705 would be included in the payment for code 28725. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for
osteotomy of the tibia (27705) billed to the enrollee for date of service April 19, 2021.