Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a 200 mg dose of Botox (J0585).
You asked the Plan to pre-approve a 200 mg dose of Botox. You say that a higher dose would give a longer
lasting effect. The Plan denied your request. The Plan says that the requested dose is not recommended.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 a 200 mg dose of Botox. Our reviewer
says that the requested dosage is medically reasonable and necessary. Our physician reviewer found Botox is
FDA-approved for up to 400 IU every 3 months.
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 200 mg dose of Botox have been met. Therefore, we decided that the Plan has
to pre-approve a 200 mg dose of Botox (J0585).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no advantage in moving the member from the current acute care hospital to an LTACH.
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. The enrollee has a significant medical history who was admitted to the hospital following for cardiac arrest. The enrollee remains critically ill. 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 he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: 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 are getting weaker, and your health is declining.
You say that the hospital is not assisting in your getting healthier. The Plan denied your request. The Plan says
the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive
the services needed 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. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for lower GI bleeding and surgical management of an inguinal hernia. The enrollee's medical
conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an EEG procedure (95816) provided on December 28, 2020, by an out of network provider.
You asked the Plan to pay for an EEG. You say that your practice is in the Plan network. The Plan denied your request. The Plan says rules for out of network care have not been met.
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.
We verified using the Plan website that the specific requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an EEG procedure (95816) provided on December 28, 2020, by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330), and crown (D2740) provided from January 20, 2021, to February 10, 2021.
You asked the Plan to pay for the dental services. You say that you thought you were covered for a crown in your dental coverage. You say that you did not realized that there was a separate dental option for an additional monthly charge. You say that you knew that you were covered up to $1,000 for dental services. You also say that when you went for a pre-treatment estimate you received a treatment that included the $1,000. The Plan denied your request. The Plan says your plan covers preventive, diagnostic, and basic dental services. The Plan says that root canal is not listed as a covered service. The Plan also says that crown 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 pay for the root canal (D3330), and crown (D2740) provided from January 20, 2021, to February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6245) for tooth #30.
You asked the Plan to pre-approve the pontic. You say that the enrollee's bridge cracked, and they need a replacement. The Plan denied your request. The Plan says the documentation does not support the need for a pontic (D6245) for tooth #30 because outdated x-rays were provided.
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 the pontic when the services are medically necessary and reasonable.
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 pontic. Our reviewer says that given the provided records, there is insufficient evidence to support the reasonableness of the requested treatment. Our physician reviewer found the request is for a four unit bridge from tooth #'s 28 to 31, replacing tooth #30 that was previously replaced on a bonded bridge from tooth #'s 29 to 31. The abutment connection on tooth #31 has failed and requires treatment. Our reviewer found that the provided full series of x-rays was dated from 2017, with a single bitewing that was recently taken showing the bond failure. The periapical regions of tooth #'s 28, 29, and 31 are not seen on current radiographs. In order to assess the reasonableness of the requested treatment the stability of the proposed abutments must be able to be assessed. Bridges can only be placed where bone support is adequate and there is no untreated endodontic involvement. Recent radiographs are necessary to allow for such assessment. Our physician reviewer also found that current x-rays should be submitted to allow for review of the treatment request. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve the pontic (D6245) for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 25, 2020.

You asked the Plan to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered.The Plan denied your request. The Plan says the record does not support that the procedures were performed 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met.Therefore, we decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 25, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external defibrillator garment provided on October 1, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services should be reprocessed as in-network. The Plan denied your request. The Plan says the 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 in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the external defibrillator garment provided on October 1, 2020, 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 punch biopsies of the skin on the bilateral calves performed on January 15, 2020.

You asked the Plan to pay for the punch biopsies. You say that the services should be paid for. The Plan denied your request. The Plan says the punch biopsies were 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 pay for the punch biopsies. Our reviewer says that the punch biopsies are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the punch biopsies were medically reasonable and necessary for the enrollee. A punch biopsy is considered the primary technique for obtaining diagnostic, full-thickness skin specimens for suspicious skin growths and lesions. The record does not provide the reason for the punch biopsies; the diagnosis reported was chronic pain. There is no indication in the record that a suspicious growth or lesion was present. 

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 punch biopsies have not been met. Therefore, we decided that the Plan does not have to pay for the punch biopsies of the skin on the bilateral calves performed on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 6 and 13 provided on December 30, 2020.
You asked the Plan to pay for the fillings provided on December 30, 2020. You say that you received a statement from the Plan saying that all your dental claims were denied. You say that at the beginning of the year you sent a $135 payment to the dentist. You also say that you need this oral evaluation as you are undergoing cancer treatment and the medications are affecting the calcium on your teeth. The Plan denied your request. The Plan says there is a $200 allowance for fillings and simple extractions. 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 fillings are listed as covered, the allowance has been exhausted.
Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 6 and 13 provided on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the elective lumbar laminectomy and decompressions (CPT code 63047).

You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the planned procedure listed under CPT code 63047 is not listed on the CMS Inpatient Only List. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay.

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 midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 63047 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory outpatient procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnight.

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 the acute inpatient hospital care for the elective lumbar laminectomy and decompressions (CPT code 63047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed (E0255), commode (E0163) and shower stall (E0240) provided on August 6, 2020 by an out of network (OON) provider.You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration because without this equipment you would not have been able to operate daily.The Plan denied your request. The Plan says covered Durable Medical Equipment and bathroom safety equipment must be purchased from a network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgentcare 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 hospital bed (E0255), commode (E0163) and shower stall (E0240) provided on August 6, 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 intraoral -periapical each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and unspecified preventative procedure, by report (D1999) provided January 11, 2021.
You asked the Plan to pay for the additional intraoral x-rays, 2D oral/facial photographic image and unspecified preventative procedure. You say that a different dentist than you had an appointment with provided your services when you arrived for your appointment and did not inform you that he was out-of-network.The Plan denied your request. The Plan says the claims have been reprocessed; however,you have met frequency limits for the intraoral x-rays and the 2D images and unspecified preventative procedure are not covered services under your dental 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. The Plan covers one intraoral x-ray per calendar year. This benefit does not list 2D images or unspecified preventative procedures as covered services.We looked at the file and Medicare rules. The Plan covered two intraoral x-rays on the same date of service. Though the Plan offers dental benefits in excess of Medicare coverage, the 2D images and unspecified preventative procedure are not among those covered services. Therefore, we decided that the Plan does not have to pay forthe intraoral -periapical each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and unspecified preventative procedure, by report (D1999) provided January 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the Medicare Part B drugs provided on
January 15, 2021.
You asked the Plan to waive the cost shares for the services provided. You say that the cost is very expensive.
The Plan denied your request. The Plan says you have a cost share based on your plan benefits.
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 20%
coinsurance for Medicare Part B prescription drugs.
The file shows that you received a Denosumab injection. You have been asked to pay a 20% coinsurance for
the services provided. The services fall within the Medicare Part B prescription drugs 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 cost shares for the Medicare Part B drugs provided on January
15, 2021.