Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says you can be treated with a BiPAP.

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 a portable ventilator. Our reviewer says that the requested portable ventilator is not medically necessary. Our physician reviewer found while the records show you have COPD as well as pulmonary fibrosis, your Carbon dioxide retention is not documented in the medical record. A bi-level positive airway pressure (BiPAP) device has not been tried. Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP devices can provide the AVAPS mode of support.

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1851) and suspension sleeve (L2397) provided on March 16, 2021.

You asked the Plan to pay for a knee brace and suspension sleeve. You say that the requested items are a necessity for the enrollee's care. 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 physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. 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 a knee brace (L1851) and suspension sleeve (L2397) provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) and reduction of osseous tuberosity (D7485).
You asked the Plan to pre-approve removal of dental bone and removal of extra bone in the roof of the mouth. You say that the dental services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your 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. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) and reduction of osseous tuberosity (D7485).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on January 25, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with CPT 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056).

You asked the Plan to pre-approve a prefabricated abutment. You say that you want the Plan to cover this service. The Plan denied your request. The Plan says the service at issue 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 a prefabricated abutment (D6056).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (37222) provided to the enrollee on February 18, 2021.
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 requested service code is not substantiated by the clinical documentation in the medical records submitted for review.
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 37222 is "open or percutaneous endovascular revascularization of an iliac artery, for each additional ipsilateraliliac vessel; with transluminal angioplasty (listed separately in addition to code for primary procedure)." 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 do not include sufficient documentation to validate that the billed procedure was performed; therefore,
this service cannot be verified. 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 (37222) provided to the enrollee on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutments, including modification and placement (D6056 x 2), an overdenture (D5865), and a ComfiLyte Denture (D5899).
You asked the Plan to pre-approve the dental services. You say that the enrollee's dentures do not stay in their mouth due to the deterioration of their gums. You also say that the enrollee's dentist advised that only a ComfiLyte denture will work for their situation. You also say that the enrollee is currently not able to eat properly. The Plan denied your request. The Plan says prefabricated abutments are not listed as covered service. The Plan says that overdenture is not listed as a covered service. The Plan says that ComfiLyte denture 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve prefabricated abutments, including modification and placement (D6056 x 2), an overdenture (D5865), and a ComfiLyte Denture (D5899).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Foundation Pain Index (FPI) testing provided on April 1, 2021.
You asked the Plan to pay for FPI testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the clinical value and effectiveness of this testing has not been established.
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 FPI testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this testing is a proprietary algorithm which is not in widespread use. It is not otherwise
considered to be a common or customary service, nor is it readily recognized by any professional society as a
standard of care. Such testing has not been demonstrated to improve the overall net outcome in patient
management.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of FPI testing have not been met. Therefore, we decided that the Plan does not
have to pay for Foundation Pain Index (FPI) testing provided on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have pre-approve routine transportation.
You asked the Plan pre-approve routine transportation. You say that the enrollee cannot drive due to vision loss. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have pre-approve routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an arthrodesis procedure of the sacroiliac joint (27279).

You asked the Plan to pre-approve arthrodesis of the sacroiliac joint. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment 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 arthrodesis of the sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested surgery may be covered when there is a "report of non-radiating, unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIJ, and consistent with sacroiliac joint (SIJ) pain." In this case the enrollee is noted to have radiating pain. The enrollee's magnetic resonance imaging (MRI) scan of the lumbar spine also showed findings suggestive of neural compression as seen on an MRI or computed tomography (CT) that correlates with the enrollee's symptoms or other more likely source for pain, in which case the rules exclude coverage of the requested procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthrodesis of the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve an arthrodesis procedure of the sacroiliac joint (27279).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve reconstruction midface identified with code 21141 and reconstruction of mandibular rami and/or body, sagittal split identified with code 21196.
You asked the Plan to pre-approve the reconstruction services. You say that you have pain from headaches and clinch your teeth because of the way your jawline is set up. The Plan denied your request. The Plan says that the requested services are 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 pre-approve the reconstruction services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation presented was relevant with respect to the condition being treated with documentation from the treating orthodontist and maxillofacial surgeon. The description of the abnormality and functional impairment was evident on viewing the various radiographs and by the patient's chief complaint (bite problems, inability to chew and headaches). The various stages of the orthodontic treatment were noted on the radiographs and the surgical consultation was noted. Therefore, you meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the reconstruction services have been met. Therefore, we decided that the Plan has to pre-approve reconstruction midface identified with code 21141 and reconstruction of mandibular rami and/or body, sagittal split identified with code 21196. 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 dental services to be performed by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON dental services. You say that it is difficult to get to the network dentists. The Plan denied your request. The Plan says medically necessary services are available in the service area with participating providers. 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. The Plan covers OON dental services when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who could provide the items/services at issue in this appeal. Based on this information, we decided that the Plan's rules for coverage of OON dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services to be performed by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Humira pen.

You asked the Plan to pre-approve the Humira pen. You say that the Humira is a continuation of therapy since 2015. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit. The Plan also says that outpatient prescription drugs are not covered by the enrollee's plan.

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 a Humira pen.

Benefits for the 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: 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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says you are medically stable, and there is no expectation that further intensive daily therapy will result in measurable gains in a reasonable and predictable period of time. 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that you require skilled nursing or skilled therapy services, i.e. the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapis are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required; therapy notes recommend treatment two to three times a week. Services in a long-term care facility on a part time basis appear appropriate 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 admission 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on March 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the denture. You say that you tried having the dental care provided by one of the Plan's providers, but you did not like their suggestions so you chose an out-of-network provider in another city to perform the procedure. The Plan denied your request. The Plan says items and services received outside of
the Plan's network are generally not covered. These services were not pre-approved, and there were other in-network providers who would have been able to provide this care.
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 the complete lower denture (D5120) provided on March 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on
March 3, 2021.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 99285 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or
physiologic function.
We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with
diagnosis codes I63.532 (Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral
artery), I63.531 (Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery),
I63.511 (Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery), and
Z20.822 (Contact with and (suspected) exposure to COVID-19). Some ICD-10-CM codes indicate laterality,
specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report left and
right diagnosis codes when a more specific (e.g. bilateral) code is available. Based on this information, we
decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we
decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on March
3, 2021