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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services would help you recover faster. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID infection and were transferred to skilled nursing facility where you received therapy services. You have been discharged home and remain weak. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 pre-approve upper and lower partial dentures.
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve upper and lower partial dentures.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the GeneSight testing.

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 that the services were not medically necessary.

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 pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has a diagnosis of major depressive disorder with moderate depression, moderate symptoms, and functional impairment. The ordering physician has indicated that the enrollee has failed therapy with three agents and that the prescriber is contemplating a change in therapy. The case file indicates that the ordering physician is a psychiatrist. The criteria for coverage are met; therefore, the testing was reasonable and 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 been met. Therefore, we decided that the Plan has to pay for the GeneSight testing.

LCD L35000 referenced by the Plan is not binding for the state to where the single-source testing was performed and was not used in the Maximus determination.

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 pay for arthroscopy, shoulder, surgical (29823) subacromial decompression (29826) provided June 16, 2020.
You asked the Plan to pay for the surgical procedure. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the service is not supported in the medical records submitted.
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 find that CPT code 29826 is not supported in the medical record. Specifically, the operative report did not include documentation of a surgical shoulder arthroscopy, with decompression of subacromial space with a partial acromioplasty, with or without coracoacromial ligament (arch) release (listed separately in addition to code for primary procedure). We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report did not include documentation of a surgical shoulder arthroscopy, with extensive debridement. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for arthroscopy, shoulder, surgical (29823) subacromial decompression (29826) provided June 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit (99283) provided on November 22, 2019.
You asked the Plan to waive the copayment for the emergency department visit. You say that you were taken to the hospital by ambulance, and you didn't want the ambulance to take you. You also say you didn't receive any services at the hospital, and you shouldn't have to pay. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency department visit. The services at issue visit fall within the emergency 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 an emergency department visit (99283) provided on November 22, 2019.
Your complaint about the ambulance taking you to the hospital when you did not want to go is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 14, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using this medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 8, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using this medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic lower back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests (85007, 85027) provided on October 30, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you were told that you would not be charged for the laboratory tests since it was done on the same day as a physical examination. The Plan denied your request. The Plan says The copayment was applied correctly.
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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory tests. The services at issue fall within the outpatient diagnostic tests 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 laboratory tests (85007, 85027) provided on October 30, 2020.
Your complaint about the potential misinformation you received is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a CGM (K0553).
You asked the Plan to pay for supplies for a CGM. You say that the enrollee is using the requested durable medical equipment with benefit. The Plan denied your request. The Plan says rules for payment have not been met.
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. Specifically, the documentation provided is not signed despite noting that a signature is required. 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 supplies for a CGM (K0553).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira Pen.
You asked the Plan to pre-approve Humira Pen. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Humira Pen.
Benefits for Humira Pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery to be provided at the inpatient hospital
level of care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says the denial of authorization for inpatient level
of care is correct, because this service can be performed in an outpatient or observation level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this
case. Our physician reviewer found observational level of care for up to 48 hours post-operative is most
appropriate. There is no need for inpatient care. This is a routine degenerative back surgery with no red flags
that require an inpatient stay.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve back surgery to be provided at the inpatient hospital level of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the fillings (D2392 x 2) provided from June 29, 2020, to September 28, 2020. You asked the Plan to waive the out of network cost share for the dental services. You say that you have multiple references that say there is a $0 copayment for exams, cleanings, and x-rays out of network. You say that they also state there is a $0 copayment for comprehensive dental services out of network. You say that you were expecting the bills to be fully covered. You also say that you feel that the printed literature is very misleading. The Plan denied your request. The Plan says the claim processed correctly. The Plan says that provider in this case is out of network. The Plan also says that out of network providers may bill you for the difference between what the provider bills and the Plan paid. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, out of network providers may bill you for the difference between what the provider bills and the Plan paid. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and the fillings (D2392 x 2) provided from June 29, 2020, to September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee orthosis (L1833) and a suspension sleeve (L2397) provided on August 22, 2020. You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using these medically necessary items with benefit. The Plan denied your request. The Plan says rules for payment have not been met. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis have not been met. Furthermore, a suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a left knee orthosis (L1833) and a suspension sleeve (L2397) provided on August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle placement (36000) and ultrasound guidance (76937) provided on October 22, 2020.
You asked the Plan to pay for needle placement and ultrasound guidance. You say that these services are supported in the records. The Plan denied your request. The Plan says these services cannot be paid 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. In this case, the CPT Code Manual definition of code 36000 is introduction of needle or intracatheter, vein, and 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). We find that CPT code 36000 and 76937 is not supported in the medical record. Specifically, code 36000 has a status code of "B," meaning payment for this service is always bundled into other services, meaning it cannot be paid separately. Code 769377 is an add-on code and cannot be paid without a covered primary procedure. Based on this information, we decided that Medicare rules for coverage of needle placement and ultrasound guidance have not been met. Therefore, we decided that the Plan does not have to pay for needle placement (36000) and ultrasound guidance (76937) provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate mandibular partial denture provided on September 29, 2020.
You asked the Plan to pay for the immediate mandibular partial denture. You say that you were told the denture would be covered at 50%. The Plan denied your request. The Plan says this service is not covered under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate mandibular partial denture provided on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is diagnosed with spinal stenosis with neurogenic claudication. The requested Vertiflex device is experimental. More research is needed to show safety and efficacy of this spacer device. Therefore, the requested Vertiflex device is not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.