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

We decided that the Plan has to pre-approve a dermatology referral.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says that the information submitted does not show a failure of two months of sedating antihistamine.

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 the referral. Our reviewer says that the requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found you need to be seen by a dermatologist. You need a thorough workup for the etiology of chronic pruritus.

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 referral have been met. Therefore, we decided that the Plan has to pre-approve a dermatology referral.

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 portable oxygen concentrator.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that this request is medically
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.

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 portable oxygen concentrator. Our
reviewer says that the requested device is not medically reasonable and necessary. Our physician reviewer
found that the medical records do not include documentation of hypoxemia during ambulation. In addition, the
order in the record is for portable oxygen, and does not specify a portable oxygen concentrator (POC). The
medical records provide no justification for a POC, rather than standard portable tanks.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 29823) provided to the enrollee on December 10, 2020.
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 the records do not support the services billed.
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 29823 is "surgical shoulder arthroscopy, with extensive debridement, including 3 or more discrete structures (humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]." We asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided do not include sufficient documentation to verify that extensive debridement was performed in multiple areas where no other work was performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 29823) provided to the enrollee on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous moderate sedation (D9239 and D9243), and cone beam computed tomography (CT) capture and interpretation (D0367), provided on January 4, 2021.

You asked the Plan to pay for the sedation and cone beam CT. You say that the services should be covered. 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. Specifically, the services received are not listed in the Plan's dental benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for the intravenous moderate sedation (D9239 and D9243), and cone beam computed tomography (CT) capture and interpretation (D0367), provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve paravertebral facet joint nerve destruction.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says that the requested service is not supported without a documented exam consistent with facet loading.The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is covered when there were two successful medial branch blocks.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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there were two diagnostic medial branch blocks at T10-T11 and T11-T12, each of which produced greater than 80% pain relief. A physical exam is noted in the appeal letter. The request meets the LCD criteria and 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 the services have been met.Therefore, we decided that the Plan has to pre-approve paravertebral facet joint nerve destruction.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 waive the copayment for injections (20610) provided August 4, 2020.

You asked the Plan to waive the copayment for the injections. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

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 $350 copayment for Outpatient Hospital services. 

You have been asked to pay a $350 copayment for the injections. The injections fall within the Outpatient Hospital 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 injections (20610) provided August 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF)care provided to the enrollee from December 5, 2020, to January 3, 2021.
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says the SNF services were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from December 5, 2020, to January 3, 2021. Based on the medical records provided, this enrollee did not require skilled therapy services during this period. Based on the medical records provided, daily skilled services were not required. The enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee from December 5, 2020, to January 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the emergency room (ER) services rendered on November 8, 2020.

You asked the Plan to waive the co-payment for these services. You say that you do not want to pay the co-payment. The Plan denied your request. The Plan says the co-payment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 co-payment for each emergency room visit.

Review of the file shows that you received ER services on November 8, 2020. You have been asked to pay a $90 co-payment for these services. These services fall within the emergency room visit 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 co-payment for the emergency room (ER) services rendered on November 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99239) provided October 22, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not separately payable.
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, we have confirmed that code 99239 has a Column One/Column Two relationship with code 99220 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99239) provided October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare identifies this item as something not covered or payable.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, and the Medicare guidelines there is no documentation that the crutch substitute (E0118) at issue in this case is medically reasonable and necessary. The code is not included in the Medicare Durable Medical Equipment fee schedule. 
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 pre-approve a crutch substitute (E0118).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for home health services

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate an urgent or emergent condition.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for home health services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 27, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes
a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays
genes in serial, then the laboratory must submit claims for genes individually. The order by the treating
clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the
patient's medical record must reflect that the service billed was reasonable and necessary.

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the
claims processing system will reject every code submitted after the first two services. However, if a lab runs
more than two distinct procedural services from this list on a single date of service, then the lab must use the 59
modifier with each additional service billed as an attestation that it is a distinct procedural service.

In this case, there were no medical records provided confirming that the labs were billed correctly. Therefore,
we decided that the Plan does not have to pay for the laboratory services provided on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from September 22, 2020 to September 25, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received inpatient hospital care on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $300 copayment per day for days 1-5 for Inpatient hospital care. We looked at the file, the Plan's contract and Medicare rules. 
The file shows that you received inpatient hospital care from September 22, 2020 to September 25, 2020. You have been asked to pay a $300 copayment per day for days 1-3, totaling $900. The inpatient hospital care falls within the Inpatient hospital care 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 the inpatient hospital care provided from September 22, 2020 to September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain crown (D2740 and a core build up (D2950),
provided on April 5, 2021.
You asked the Plan to pay for a crown and core build up. You say that the services should be covered. The Plan
denied your request. The Plan says you have exceeded your Plan's dental allowance.
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. Specifically, you have exceeded your Plan's dental allowance, and
therefore, are responsible for the difference. Therefore, we decided that the Plan does not have to pay for a
porcelain crown (D2740 and a core build up (D2950), provided on April 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health skilled nursing care.You asked the Plan to pre-approve continuation of home health skilled nursing care. You say that this care is medically necessary.The Plan denied your request. The Plan says this care is no longer medically necessary.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 continuation of home health skilled nursing care. Our reviewer says that the requested home health skilled nursing care is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is not homebound. As such,home health skilled care is not medically necessary or reasonable. While the enrollee may require supervision due to his psychiatric illness, such care is custodial and does not necessitate a daily skilled nurse visit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of home health skilled nursing care have not been met.Therefore, we decided that the Plan does not have to pre-approve continuation of home health skilled nursing care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide a PET/CT.You asked the Plan to provide a PET/CT for attenuation correction and anatomical localization imaging; whole body (78816). You say that you want to rule out metastatic disease so you can consider proceeding with local treatment.The Plan denied your request. The Plan says Medicare does not cover PET scans for initial diagnosis and staging for the enrollee's diagnosis.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 provide a PET/CT for attenuation correction and anatomical localization imaging; whole body (78816). Our reviewer says that a PET/CT is not medically necessary. Our physician reviewer found the PET/CT is indicated for suspected prostate cancer recurrence based on elevated Prostate Specific Antigen (PSA) levels following treatment. Criteria is not met. Patient has not been treated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body (78816) have not been met.Therefore, we decided that the Plan does not have to provide a positron emission tomography (PET) with concurrently acquired computed tomography (CT).