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

We decided that the Plan does not have to pre-approve a heart computed tomography (CT).

You asked the Plan to pre-approve a heart CT. You say that there is a family history of heart disease. The Plan denied your request. The Plan says screening heart CTs are not covered by Medicare or the Plan.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a heart CT, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a heart computed tomography (CT).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 19, 2020, to October 23, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for inpatient level of care is correct, because inpatient criteria were not met, and this stay could have been provided as observation.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency room on October 19, 2020. She was admitted and treated with Unasyn to cover possible urinary tract infection. Prior to discharge, antibiotics were stopped and the enrollee did not have any relapse. The possibility of recurrent seizure was entertained. The enrollee underwent 48-hour electroencephalography monitoring. Her medication list was reviewed and medication was adjusted. She was discharged home when considered medically stable on October 23, 2020. At the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency and/or observation care) would span at least 2 midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 19, 2020, to October 23, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection services.
You asked the Plan to pre-approve injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain indications. 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 injection services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had therapeutic lumbar facet injections and these produced 70% pain relief, but the duration of that pain relief is not documented. The request appears to be short of the LCD specified time requirement. Therefore, the enrollee does not 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 injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve injection services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for TruGraf Blood testing (81479) provided on October 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the TruGraf Blood testing. You say that this testing is medically necessary and covered by Medicare. The Plan denied your request. The Plan says these 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 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 TruGraf Blood testing (81479) provided on October 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction to be provided by an oral surgeon.
You asked the Plan to pre-approve a dental extraction to be provided by an oral surgeon. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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. Review of the file shows that the plan only covers dental services that are provided by a general dentist. You are requesting these services be provided by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a dental extraction to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on July 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says the unauthorized services were provided by a non-participating 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 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 podiatry services provided on July 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on July 10, 2020.
You asked the Plan to pay for the hospital discharge day management. You say that the physician only provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not
need an intensive rehab program, with a team of specialized healthcare professionals.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for altered mental status and blurry vision. Medical
problems are stable. There are no complex nursing needs. The patient does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an incision (27303) and a revision of a total knee arthroplasty (27486) provided on March 6, 2020.
You asked the Plan to pay for an incision and a revision of a total knee arthroplasty. You say that these codes are supported. The Plan denied your request. The Plan says these procedures are not documented.
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 27303 incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) and 27486 is revision of total knee arthroplasty, with or without allograft; 1 component. 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 incision and a revision of a total knee arthroplasty. Our reviewer says that these codes are not supported in the record as billed. Our physician reviewer found the submitted records do not confirm that CPT 27303 was provided as the operative report does not document that opening was performed. CPT 27486 is confirmed in the operative report, but this code should be reported with modifier 52 should be appended with procedure code. CPT 27486 consists of removing the poly liner, removing a prosthetic, and replacing it with a new prosthesis. When just replacing the poly liner, modifier 52 would be used since the full service defined by the code descriptor was not performed. 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 incision and a revision of a total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for an incision (27303) and a revision of a total knee arthroplasty (27486) provided on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat and bathtub handrails.
You asked the Plan to pre-approve the requested items. You say that the enrollee no longer has the strength to ambulate freely at home. The Plan denied your request. The Plan says the items are excluded from coverage.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While the items at issue in this case may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat and bathtub handrails.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6057, D6058).
You asked the Plan to pre-approve the services. You say that this is needed due to dental cap. The Plan denied your request. The Plan says this is not covered under the dental contract under any normal circumstances.
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 dental services (D6057, D6058).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, pain assessment, and document attestation provided on September 13, 2020.
You asked the Plan to pay for the initial hospital care, pain assessment, and document attestation. You say that you would like this claim to be covered. The Plan denied your request. The Plan says the Medicare Hospice benefit, through fee-for-service Medicare, covers all Hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the initial hospital care, pain assessment, and document attestation provided on September 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 15, 2020.
You asked the Plan to pay for the dental service. You say that your dentist did not check to see if the 3 year period had elapsed so that this service would be covered. You say that this information would not have even been available because your previous dental office is closed. You also say that you had no warning that your previous dental office was going to close. 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 for this service 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, the frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 19, 2018. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 15, 2020.
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 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. 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 medically necessary. Our physician reviewer found you were admitted to the hospital with an infection of recent spinal surgery site and were treated with antibiotics and surgery. Your medical problems are now stable. You have 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. You may benefit from further therapy but do not require an intensive therapy program in an IRF and there is not a reasonable expectation that you will be able to fully participate in and benefit from such a program.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen equipment (E1390, E1392) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve oxygen equipment. You say that this supplier is superior to network suppliers because it employs respiratory therapists. The Plan denied your request. The Plan says both oxygen equipment and respiratory therapists are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve oxygen equipment (E1390, E1392) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 16, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the place of service must reflect the location of the enrollee when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that the place where the sample was taken is reported as the Place of Service. We looked at the file and the rules. The provided claim shows a place of services as 81, which indicates an independent lab. The records provided do not show that the enrollee's specimen was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial mandibular denture cast (D5214).

You asked the Plan to pre-approve the denture cast. You say that you had a tooth pulled at the end of 2020 which left only one tooth for your denture to connect on. You want this service to be redone so that you can have a properly fitted denture. The Plan denied your request. The Plan says this service is not covered by Medicare and is only covered by your supplemental dental benefit once every five years. You last had this service; therefore, this service cannot be covered as it was last provided less than five years ago.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, this service is only covered once every five years. Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture cast (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device remains experimental for the treatment of spinal stenosis. More research is needed to show safety and efficacy of the device.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.