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

We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) nuclear medicine localization of tumor or inflammation or study of distribution of radioactive tracer in single area (78803).
You asked the Plan to pre-approve SPECT services. You say that these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the relevant coverage criteria for these services have not been met.
The Plan follows Medicare rules. Medicare rules say that SPECT services are subject to the criteria listed 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 SPECT services. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the enrollee has non-ischemic cardiomyopathy with an ejection fraction of 46% that has improved with treatment of hypertension. In this case, the record indicates a normal free chain ration. The record does not indicate how this test will be used to alter management. The record does not indicate that the enrollee has known amyloidosis. The elements of the coverage criteria are not satisfied 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 SPECT services have not been met. Therefore, we decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) nuclear medicine localization of tumor or inflammation or study of distribution of radioactive tracer in single area (78803).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the global service (professional and technical components) of the
screening mammogram and digital tomosynthesis provided on November 11, 2020, billed with codes 77063
and 77067.
You asked the Plan to pay for the screening mammogram and digital tomosynthesis. You say that this was rebilled
on a corrected claim since Medicare requires these services to be billed separately. The Plan denied your
request. The Plan says that billing both components on separate line items is not appropriate, and as such,
denial was correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, two claims were submitted for these services. The original claim
included this screening with other services provided on the same date. This was denied on November 11, 2020
stating that the coding should be verified. You then submitted a corrected claim in which each code was billed
twice, separating the technical and professional components. The Plan denied this claim on February 14, 2021,
as it is not appropriate to bill as such. While the denial of the corrected claim appears appropriate as there is no
reason to separate these components when the global service was provided, we find that there is not sufficient
evidence to support that denial of the original claim was correct.
In your appeal, you indicate that Medicare requires these mammography services to be billed on a separate
claim from any other services provided. This is not the reason that the Plan denied this original claim. We were
unable to find any rule regarding billing for screening mammography that indicates these services must be
billed separately from other services. Based on the entirety of the very limited case file, we find that there is no
justification for the denial of the original claim. The Plan failed to justify why payment was denied originally
which led to the corrected claim being submitted. We find that non-payment for the services rendered is not
supported. we Therefore, we decided that the Plan has to pay for the global service (professional and technical
components) of the screening mammogram and digital tomosynthesis provided on November 11, 2020, billed
with codes 77063 and 77067.
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 pre-approve a core buildup (D2950) for tooth #18 and a therapeutic drug injection (D9610).
You asked the Plan to pre-approve the core buildup and drug injection. You say that you feel that the services requested are necessary and should be covered. The Plan denied your request. The Plan says you were approved for the cleaning, fillings, and crowns that were requested, including the crown for tooth #18. However, core buildup is not covered by your benefit, nor is the use of injected drugs.
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 codes for the requested services are not listed as covered in the 2021 Dental Benefit Schedule for your Plan. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950) for tooth #18 and a therapeutic drug injection (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy pump (E2402).

You asked the Plan to pre-approve a Negative Pressure Wound Therapy pump. You say that this service is medically necessary.The Plan denied your request. The Plan says this item is no longer medically necessary.

The Plan follows Medicare rules. Medicare rules say that a Negative Pressure Wound Therapy pump and supplies will be denied as no longer medically reasonable and necessary when a treating practitioner states adequate wound healing has occurred.

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 Negative Pressure Wound Therapy pump. Our reviewer says that the requested Negative Pressure Wound Therapy pump is no longer medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has a sacral ulcer that has been treated with a wound vacuum pump. The record indicates that the wound is 99% healed and that the wound vac was not to be used but was not to be returned. The treating practitioner has discontinued the use of the device.  The criteria for non-coverage have been satisfied as adequate wound healing has occurred.

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 Negative Pressure Wound Therapy pump have not been met.Therefore, we decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy pump (E2402).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the portable x-ray services (71045, R0070 and Q0092) provided on March 26, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that you would like reconsideration because the service provided was medically necessary as the member is homebound. The Plan denied your request. The Plan says that the rendered services were not urgent, emergent or approved in advance.
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 provider at issue in this case is not a network provider with the Plan. 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 portable x-ray services. Our reviewer says that the obtained portable x-ray was medically necessary due to the member's homebound condition. Our physician reviewer found the review indicates that the enrollee is homebound and had complaints of shortness of breath and hemoptysis. 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 portable x-ray services have not been met. 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 pay for the portable x-ray services. Therefore, we decided that the Plan has to pay for the portable x-ray services (71045, R0070 and Q0092) provided on March 26, 2021 by an out of network (OON) provider.
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 the dental services provided July 10, 2020.
You asked the Plan to pay for the dental services. You say that you are uncomfortable taking the enrollee to the hospital and would like these dental services covered. The Plan denied your request. The Plan says these dental services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided July 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for radiology services you received on October 20, 2020.
You asked the Plan to waive the deductible for the radiology services. You say that you did not understand how the deductible worked and it is not fair that you have to pay it. The Plan denied your request. The Plan says these services were appropriately applied to your deductible. The Plan says that you had not yet met your yearly deductible at the time of the services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 annual deductible that applies to radiological diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 annual deductible that applies to radiological diagnostic services. This cost sharing is a contractual obligation that had not been met at the time the radiology services were received on October 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for radiology services you received on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 13, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 3, 2020.
You asked the Plan to pay for the dental service. You say that you switched dental offices. You also say that this was your first exam with that office. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on December 18, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Minuteman spinal fusion procedure.
You asked the Plan to pre-approve the Minuteman spinal fusion procedure. You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the services are 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 pre-approve the Minuteman spinal fusion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has degenerative disc disease of the lumbar spine with moderate to severe central canal stenosis. The Food and Drug Administration states that the Minuteman procedure is intended for plate fixation/attachment to spinous processes for the purpose of achieving supplemental fusion. The record indicates that the Minuteman device is being used as a primary treatment rather than a supplement. The required elements of the coverage criteria are not satisfied.
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 Minuteman spinal fusion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Minuteman spinal fusion procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met
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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. Your physical function is at or near her baseline and she can receive services at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of LTACH services.
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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0673) provided on January 13, 2021.
You asked the Plan to pay for an intermittent limb compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are covered by Medicare only for treatment of lymphedema or of chronic venous insufficiency with venous stasis ulcers.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0673) provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and the unspecified periodontal procedure, by report (D4999) received March 3, 2021.
You asked the Plan to pay for the oral hygiene instructions and the unspecified periodontal procedure. You say that the Plan should play for the requested services. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 the oral hygiene instructions (D1330) and the unspecified periodontal procedure, by report (D4999) received March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for presumptive drug class screening (80306) electrocardiogram (93005) provided on June 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that please see attached medical records to support charges. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 presumptive drug class screening (80306) electrocardiogram (93005) provided on June 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953), and the guided tissue regeneration (D4266) provided on January 13, 2021.
You asked the Plan to pay for the bone replacement graft and guided tissue regeneration. You say that you are on a fixed income. You say that the amount of an implant is shocking. You also say that you do not want the implant for cosmetic purposes, only to fill the gap in your mouth. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service. The Plan says that guided tissue regeneration is not listed as a covered service either.
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 bone replacement graft and guided tissue regeneration are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953), and the guided tissue regeneration (D4266) provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder brace provided on September 18, 2020.
You asked the Plan to pay for the shoulder brace. You say that this was medically necessary and should be reimbursed. The Plan denied your request. The Plan says there is missing documentation to support payment for this claim.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Though an order and an alleged exam is included in the documentation, there is no proof that this item was shipped or delivered on the date of service in question. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder brace provided on September 18, 2020.