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

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician consults, and daily labs. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the present acute care facility.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH). Initially treated for bradycardia, the enrollee was subsequently found to have a colonic mass. Given his age and overall medical conditional, additional evaluation of the mass is not expected. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diclofenac gel.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing.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 diclofenac gel.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Superion Vertiflex Procedure.You asked the Plan to pre-approvea surgical insertion of an interspinous process spacer. You say that clinical and diagnostic patient specific data is in support of medical necessity.The Plan denied your request.The Plan says there is not enough medical evidence that shows the procedure is safe and helpful.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 a surgical insertion of an interspinous process spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is 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 a surgical insertion of an interspinous process spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Superion Vertiflex Procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -three surfaces, anterior (D2332) and resin-based composite -one surface, posterior (D2391) provided on February 5, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit 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.You met your maximum plan benefit coverage of $500 per year during services rendered on January 16, 2020. Your EOC clearly states, you are responsible for any cost above the $500 maximum.Therefore, we decided that the Plan does not have to pay forresin-based composite -three surfaces, anterior (D2332) and resin-based composite -one surface, posterior (D2391) provided on February 5, 2020.
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 it is felt that LTACH care would be the best option. The Plan denied your request. The Plan says there is no services that is required that cannot be provided in the current facility. Therefore, transfer is not medically necessary.
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, intravenous antibiotics, wound care, glucose control and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74178).You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says that rules for coverage were not.The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the CT scan. Our reviewer says that coverage criteria has been met. Our physician reviewer found the patient has microscopic hematuria with no signs or symptoms of urinary tract infection to account for the blood. A CT scan is appropriate.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 CT scan have been met.Therefore, we decided that the Plan has to pre-approveComputed Tomography (CT) of the abdomen and pelvis (74178).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitriptyline HCL for the enrollee.
You asked the Plan to pre-approve Amitriptyline HCL. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Amitriptyline HCL for the enrollee.
Benefits for Amitriptyline HCL 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-approvea non-invasive home ventilator (E0466).You asked the Plan to pre-approvethe ventilator. You say that the device is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the patient has severe COPD, but there is no documentation of CO2 retention. The patient was started on ventilator support at home, at night, in December 2019, but usage documentation does not meet minimum coverage criteria, and usage is insufficient for significant medical benefit. The ventilator is being used as a BiPAP device, which Medicare does not cover.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 ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea non-invasive home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 9, 2019.You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 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 services are not medically necessary. Our physician reviewer found the enrollee has low back pain rated at 8 out of 10. She has decreased lumbar range of motion and tenderness. There is no evidence of a failure of conservative treatments known to be effective for treating low back pain related to facet arthropathy. She has not failed physical therapy or has a history of intolerance to physical therapy treatments and has is not currently performing a home exercise program. The MBBs are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks (MBBs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have left
groin, hip, and buttock pain. An x-ray of the pelvis on January 31, 2020 showed mild degenerative arthritis of
the left hip joint and mild to moderate degenerative arthritis of the right hip. There is no evidence of
inflammation of the SI joint on diagnostic testing. The requested injection is not the standard of care for your
condition and is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided January 15, 2020.You asked the Plan to pay for the x-rays. You say that you feel that you needed this test because you were having trouble with your lower teeth and wanted to see how your jawbone is. You're trying to save your teeth.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for panoramic x-rays (D0330) provided January 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from October 2, 2019 to October 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a valid HIPPS and Treatment Authorization code. We looked at the file and Medicare rules. The claims were not billed with valid HIPPS or treatment authorization codes. 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 pay for the home health services rendered from October 2, 2019 to October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system for your power wheelchair.You asked the Plan to pre-approve a power seat elevation system. The Plan denied your request. The Plan says the seat elevator does not serve a primary medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system for your power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 30, 2019. You asked the Plan to pay for the services. You say that lab services provided to the enrollee on September 30, 2019. 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 the denied codes is: CPT 80157: Carbamazepine; free CPT 80177: Levetiracetam CPT 80201: Topiramate CPT 80159: Clozapine CPT 80173: Haloperidol 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 services at issue in this case were not coded correctly. Our physician reviewer found the lab report indicates that the tested specimen was urine. Therefore, the billing of codes indicating that the testing was performed on blood is not supported. 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 lab services provided to the enrollee on September 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S9122 and A0888), a toilet rail (E0243), a wheelchair (E1038), and a walker (E0243) provided by providers who do not participate in Medicare from September 14, 2019 to December 1, 2019.You asked the Plan to pay for home health services, a toilet rail, a wheelchair, and a walker provided by providers who do not participate in Medicare. You say that you did not know you needed to use providers who participate in Medicare.The Plan denied your request. The Plan says providers who do not participate in Medicare cannot be paid.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The provider you received these services from does not participate in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services, a toilet rail, a wheelchair, and a walker provided by providers who do not participate in Medicare have not been met.Therefore, we decided that the Plan does not have to pay for home health services (S9122 and A0888), a toilet rail (E0243), a wheelchair (E1038), and a walker (E0243) provided by providers who do not participate in Medicare from September 14, 2019 to December 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forprefabricated hip orthosis (L1686) hip joint, adjustableflexion, extension, abduction control (L2624) provided on July 16, 2019.You asked the Plan to pay forthe orthoses. You say that the only difference with the deliver ticket would be the addition of the in-house shipping ticket that the enrollee issent with the equipment.The Plan denied your request. The Plan says the records provided do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that supplier-produced records, even if signed by the prescribing physician/practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forprefabricated hip orthosis (L1686) hip joint, adjustable flexion, extension, abduction control (L2624) provided on July 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 77065) provided on July 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 77065 is "Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral". 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 use of CPT code 77065 is not supported by the records provided. Our physician reviewer found that the 2-view mammography done after the ultrasound guided biopsy is considered a part of the guidance procedure and as such is not a separate billable charge. 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 the services (CPT 77065) provided on July 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on January 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out-of-network provider.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the CT scan provided on January 6, 2020 by an out of network (OON) provider.